Susan M. Frayne, MD, MPH

All Publications

Mental Health and Obesity Among Veterans: A Possible Need for Integrated Care. Psychiatric services (Washington, D.C.) Breland, J. Y., Frayne, S. M., Timko, C., Washington, D. L., Maguen, S. 2020: appips201900078
Abstract

OBJECTIVE: The goal was to examine psychiatric diagnosis rates among a national cohort of primary care patients with and without obesity.METHODS: The cohort was derived from national Veterans Health Administration data (women, N=342,262; men, N=4,524,787). Sex-stratified descriptive statistics characterized psychiatric diagnosis rates. Chi-square tests determined whether diagnosis rates differed by obesity status (alpha=0.001).RESULTS: Rates of any psychiatric diagnosis were higher among women than among men and among people with obesity versus without obesity (women, 53.9% vs. 50.4%; men, 37.9% vs. 35.2%). Depression and posttraumatic stress disorder diagnosis rates were higher for people with obesity, and substance use disorder diagnosis rates were lower for people with obesity. Anxiety diagnosis rates were slightly lower among women with obesity versus women without obesity.CONCLUSIONS: Programs simultaneously addressing weight management and mental health could address the psychiatric comorbidities observed among people with obesity. Women are most likely to need these services.

View details for DOI 10.1176/appi.ps.201900078

View details for PubMedID 31996116
Sex Differences in Veterans' Cardiovascular Health JOURNAL OF WOMENS HEALTH Whitehead, A. M., Maher, N. H., Goldstein, K., Bean-Mayberry, B., Duvernoy, C., Davis, M., Safdar, B., Saechao, F., Lee, J., Frayne, S. M., Haskell, S. G. 2019; 28 (10): 1418–27
View details for DOI 10.1089/jwh.2018.7228

View details for Web of Science ID 000490648800015
Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study. Women's health issues : official publication of the Jacobs Institute of Women's Health Schmidt, E. M., Magruder, K., Kilbourne, A. M., Stock, E. M., Cypel, Y., El Burai Felix, S., Serpi, T., Kimerling, R., Cohen, B., Spiro, A., Furey, J., Huang, G. D., Frayne, S. M. 2019
Abstract

OBJECTIVES: We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era.METHODS: For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965-1973 completed a health interview in 2011-2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service.RESULTS: Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15-0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11-1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard.CONCLUSIONS: Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.

View details for DOI 10.1016/j.whi.2019.08.002

View details for PubMedID 31519465
Patient and Health Care Factors Associated With Long-term Diabetes Complications Among Adults With and Without Mental Health and Substance Use Disorders. JAMA network open Schmidt, E. M., Barnes, J., Chen, C., Trafton, J., Frayne, S., Harris, A. H. 2019; 2 (9): e1912060
Abstract

Importance: Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote long-term medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management.Objective: To analyze how preexisting MH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications.Design, Setting, and Participants: This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017.Exposures: Patients were assigned to groups on the basis of a 2-year look-back period for MH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or no MH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabetes was diagnosed.Main Outcomes and Measures: Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores.Results: Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexisting MH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, -0.09; 95% CI, -0.13 to -0.04; P<.001) or both MH and SU disorders (decrease in DCSI score, -0.13; 95% CI, -0.16 to -0.09; P<.001), but not MH disorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, -0.41 [95% CI, -0.43 to -0.39] for 1-2 visits, -0.50 [95% CI, -0.52 to -0.48] for 3-4 visits, -0.39 [95% CI, -0.41 to -0.37] for 5-8 visits, and -0.15 [95% CI, -0.17 to -0.12] for ≥9 visits; P<.001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P<.001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P=.004; or both MH and SU disorders, 0.008 [95% CI, 0.006-0.011], P<.001), compared with patients without MH or SU disorders.Conclusions and Relevance: Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.

View details for DOI 10.1001/jamanetworkopen.2019.12060

View details for PubMedID 31553472
Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. Journal of general internal medicine Cordasco, K. M., Frayne, S. M., Kansagara, D., Zulman, D. M., Asch, S. M., Burke, R. E., Post, E. P., Fihn, S. D., Klobucar, T., Meyer, L. J., Kirsh, S. R., Atkins, D. 2019
Abstract

Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

View details for DOI 10.1007/s11606-019-04970-3

View details for PubMedID 31098966
Sex Differences in Veterans' Cardiovascular Health. Journal of women's health (2002) Whitehead, A. M., Maher, N. H., Goldstein, K., Bean-Mayberry, B., Duvernoy, C., Davis, M., Safdar, B., Saechao, F., Lee, J., Frayne, S. M., Haskell, S. G. 2019
Abstract

BACKGROUND: In the U.S. civilian population, sex differences have been identified in cardiovascular health; these differences have been used to inform care. Our objective is to determine if the same sex differences are present in Veterans who use the Department of Veterans Affairs (VA) Health Care System given the additional stressors associated with military service.METHODS: Cardiovascular disease (CVD) risk factors and conditions among women and men Veterans using VA in fiscal year (FY) 2014 were identified through the presence of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes in VA administrative records. ICD-9-CM codes were grouped into conditions; prevalence was examined by gender overall, by age, and by race/ethnicity.RESULTS: Within the FY 2014 cohort of VA Veteran patients included in this analysis, 7.1% (n=412,901) were women and 92.9% were men (n=5,376,749). Compared with men, women in this cohort were younger and more ethnically diverse. Overall, women were less likely to have traditional CVD risk factors, but more likely to have a nontraditional CVD risk factor (depression) compared with men. Women had higher odds of chest pain/angina (adjusted odds ratio [AOR] 1.03, confidence interval [95% CI] 1.02-1.05), palpitations (AOR 2.04; 95% CI 1.98-2.10), and valvular disease (AOR 1.05; 95% CI 1.02-1.08), but lower odds of coronary artery disease (AOR 0.29; 95% CI 0.29-0.30), acute MI (AOR 0.46; 95% CI 0.43-0.49), and heart failure (AOR 0.55; 95% CI 0.53-0.56) compared with men, overall.CONCLUSIONS: In age-adjusted comparisons, sex differences in the prevalence of CVD risk factors and conditions among the VA Veteran patient population was similar in that seen in the civilian population with a few exceptions.

View details for PubMedID 30839237
Racial/Ethnic Disparities in Mortality Across the Veterans Health Administration. Health equity Wong, M. S., Hoggatt, K. J., Steers, W. N., Frayne, S. M., Huynh, A. K., Yano, E. M., Saechao, F. S., Ziaeian, B., Washington, D. L. 2019; 3 (1): 99–108
Abstract

Purpose: Equal-access health care systems such as the Veterans Health Administration (VHA) reduce financial and nonfinancial barriers to care. It is unknown if such systems mitigate racial/ethnic mortality disparities, such as those well documented in the broader U.S. population. We examined racial/ethnic mortality disparities among VHA health care users, and compared racial/ethnic disparities in VHA and U.S. general populations. Methods: Linking VHA records for an October 2008 to September 2009 national VHA user cohort, and National Death Index records, we assessed all-cause, cancer, and cardiovascular-related mortality through December 2011. We calculated age-, sex-, and comorbidity-adjusted mortality hazard ratios. We computed sex-stratified, age-standardized mortality risk ratios for VHA and U.S. populations, then compared racial/ethnic disparities between the populations. Results: Among VHA users, American Indian/Alaskan Natives (AI/ANs) had higher adjusted all-cause mortality, whereas non-Hispanic Blacks had higher cause-specific mortality versus non-Hispanic Whites. Asians, Hispanics, and Native Hawaiian/Other Pacific Islanders had similar, or lower all-cause and cause-specific mortality versus non-Hispanic Whites. Mortality disparities were evident in non-Hispanic-Black men compared with non-Hispanic White men in both VHA and U.S. populations for all-cause, cardiovascular, and cancer (cause-specific) mortality, but disparities were smaller in VHA. VHA non-Hispanic Black women did not experience the all-cause and cause-specific mortality disparity present for U.S. non-Hispanic Black women. Disparities in all-cause and cancer mortality existed in VHA but not in U.S. population AI/AN men. Conclusion: Patterns in racial/ethnic disparities differed between VHA and U.S. populations, with fewer disparities within VHAs equal-access system. Equal-access health care may partially address racial/ethnic mortality disparities, but other nonhealth care factors should also be explored.

View details for DOI 10.1089/heq.2018.0086

View details for PubMedID 31289768
Impact of Wartime Stress Exposures and Mental Health on Later-Life Functioning and Disability in Vietnam-Era Women Veterans: Findings from The Health of Vietnam-Era Women's Study (HealthViEWS). Psychosomatic medicine Smith, B. N., Spiro, A., Frayne, S. M., Kimerling, R., Cypel, Y., Reinhard, M. J., Kilbourne, A. M., Magruder, K. M. 2019
Abstract

The effect of stress exposures and mental health sequelae on health-related outcomes is understudied among older women veterans. We examined (1) the impact of wartime stress exposures on later-life functioning and disability in Vietnam-era women veterans, and (2) the extent to which mental health conditions known to be associated with stress-posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD)-are associated with additional later-life functioning and disability.Data were collected in 2011-2012 using a mail survey and telephone interview of 4,219 women veterans who were active duty during the Vietnam Era. Health functioning was assessed using the Veterans RAND 36-Item Health Survey, and disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Wartime exposures were assessed using the Women's War-Zone Stressor Scale-revised; the Composite International Diagnostic Interview, version 3.0 was used to assess PTSD, MDD, and GAD.Several wartime stress exposures-including job-related pressures, dealing with death, and sexual discrimination and harassment-were associated with worse later-life health (β ranges: -0.04 - -0.26 for functioning, 0.05 - 0.30 for disability). Current PTSD was linked with lower health functioning (physical: β = -0.06; mental: β = -0.15) and greater disability (β = -0.14). Current MDD and GAD were also associated with lower mental health functioning (MDD: β = -0.29; GAD; β = -0.10) and greater disability (MDD: β = 0.16; GAD; β = 0.06).Results underscore the importance of detection and treatment for the potential long-term effects of wartime stressors and mental health conditions among women veterans.

View details for DOI 10.1097/PSY.0000000000000762

View details for PubMedID 31714370
Substance Use Disorder-Related Disparities in Patient Experiences of Primary Care. Health equity Hoggatt, K. J., Frayne, S. M., Saechao, F. S., Yano, E. M., Washington, D. L. 2019; 3 (1): 193–97
Abstract

Purpose: To assess disparities in primary care experiences for patients with a substance use disorder (SUD) diagnosis. Methods: We assessed differences in Veterans Health Administration (VA) primary care patients' experiences using data from the 2014 outpatient VA Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (SHEP; N=286,026). We obtained patient demographics and diagnoses from VA electronic medical record data. Results: Patients with an SUD diagnosis reported worse experiences for 8 of 12 SHEP measures, including access, provider communication, and information received (p<0.05). Conclusion: Targeted strategies may be needed to ensure patients with SUD have favorable primary care experiences.

View details for DOI 10.1089/heq.2018.0069

View details for PubMedID 31289779
Obesity and Health Care Experiences among Women and Men Veterans. Women's health issues : official publication of the Jacobs Institute of Women's Health Breland, J. Y., Wong, M. S., Frayne, S. M., Hoggatt, K. J., Steers, W. N., Saechao, F., Washington, D. L. 2019; 29 Suppl 1: S32–S38
Abstract

Obesity is highly stigmatized, especially for women, and therefore may negatively affect health care experiences. Past findings on the relationship between obesity and health care experiences are mixed, perhaps because few studies examine relationships by gender and obesity class. Our objective was to evaluate whether women and men with more severe obesity report worse health care experiences related to Veterans Health Administration (VA) care.Health care experiences (self-management support, mental health assessments, office staff courtesy, communication with providers) and overall provider ratings were assessed with the 2014 VA Survey of Health Care Experiences of Patients. Using multiple regression analyses (n = 13,462 women, n = 268,180 men), we assessed associations among obesity classes, health care experiences, and overall provider ratings, adjusting for sociodemographic, health, and primary care use characteristics.The greatest differences in health care experiences between patients with and without obesity were in self-management support experiences, which were more favorable among women and men of all obesity classes. There were gender differences in associations between obesity and mental health assessments: for men, but not women, those in any obesity class gave higher ratings than those without obesity. For most other health care experiences and provider ratings, men with obesity reported slightly less favorable experiences than those without. There was no consistent pattern for women.It is promising that VA patients with obesity report more self-management support, given the behavior change required for weight management. Lower health care experience and provider ratings among men with obesity suggest a need to further investigate possible obesity-related stigma in VA primary care.

View details for DOI 10.1016/j.whi.2019.04.005

View details for PubMedID 31253240
Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data. Health services research Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018
Abstract

OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

View details for PubMedID 30198185
Practice-based research networks add value to evidence-based quality improvement HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION Goldstein, K. M., Vogt, D., Hamilton, A., Frayne, S. M., Gierisch, J., Blakeney, J., Sadler, A., Bean-Mayberry, B. M., Carney, D., DiLeone, B., Fox, A. B., Klap, R., Yee, E., Romodan, Y., Strehlow, H., Yosef, J., Yano, E. M. 2018; 6 (2): 128–34
Abstract

This study evaluated the Implementation of Essential Health Care Program (EHCP) in the Department of Education - Schools Division of Tarlac Province during the School Year 2014-2015 in partnership with the Provincial Government of Tarlac (PGT).The Context Input Process Product (CIPP) evaluation model was used in the study. The questionnaire, documentary analysis, interview and observation were used in the data gathering. Documents that were available such as records and DepED memoranda and orders were used as sources of data. Tables were utilized to analyze the data.The study found that the implementation of the EHCP was outstanding in its administration and personnel while very satisfactory in its strategies. The supplies were very adequate and adequate in its financial resources and facilities. The extent/level of the attainment of implementation of its component was fully attained/implemented in the daily handwashing with soap, toothbrushing with fluoride toothpaste and bi-annual deworming while on the additional dental services incorporated to the EHCP were fully attained/implemented on fluoride application, atraumatic restorative treatment (ART) and pits and fissure sealant. The successful implementation of the were attributed to the full implementation of the activities in each component in compliance with the DepED memoranda and orders, supervision of School Health and Nutrition Section and support of the program administrators and program implementers, cooperation and participation of the program beneficiaries and the full support of the Provincial Government of Tarlac.The EHCP has been successfully implemented however there are problems that are seldom encountered and action plan was proposed to address the said problems.

View details for PubMedID 28711505
Enhancing multilevel stakeholder engagement in implementation research: perspectives of implementation scientists Hamilton, A., Frayne, S., Yano, E. BIOMED CENTRAL LTD. 2018
View details for Web of Science ID 000428652000128
Physical Health Conditions Among a Population-Based Cohort of Vietnam-Era Women Veterans: Agreement Between Self-Report and Medical Records JOURNAL OF WOMENS HEALTH Kilbourne, A. M., Schumacher, K., Frayne, S. M., Cypel, Y., Barbaresso, M. M., Nord, K. M., Perzhinsky, J., Lai, Z., Prenovost, K., Spiro, A., Gleason, T. C., Kimerling, R., Huang, G. D., Serpi, T. B., Magruder, K. M. 2017; 26 (11): 1244–51
Abstract

Little is known about medical morbidity among women Vietnam-era veterans, or the long-term physical health problems associated with their service. This study assessed agreement comparing data on physical health conditions from self-report and medical records from a population-based cohort of women Vietnam-era Veterans from the Health of Vietnam Era Women's Study (HealthViEWS).Women Vietnam-era veterans (n = 4219) self-completed a survey and interview on common medical conditions. A subsample (n = 900) were contacted to provide permission to obtain medical records from as many as three of their providers. Medical record reviews were conducted using a standardized checklist. Agreement and kappa (agreement beyond chance) were calculated for physical health condition groups.Of the 900, 449 had medical records returned, and of those, 412 had complete surveys/interviews. The most commonly reported conditions based on self-report or medical record review included hypertension, hyperlipidemia, or arthritis. Kappa scores between self-reported conditions and medical record documentation were 0.75-0.91 for hypertension, diabetes, most cancers, and neurological conditions, but lower (k = 0.29-0.55) for cardiovascular diseases, musculoskeletal, and gastrointestinal conditions. Generally, agreement did not significantly vary by different sociodemographic groups.There was relatively high agreement for physical health conditions when self-report was compared with medical record review. As more women are increasingly represented in the military and more veterans in general seek care outside the Veterans Health Administration, accurate measurement of physical health conditions among population-based samples is crucial.

View details for PubMedID 28783423
Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease HEART Yang, F., Hellyer, J. A., Than, C., Ullal, A. J., Kaiser, D. W., Heidenreich, P. A., Hoang, D. D., Winkelmayer, W. C., Schmitt, S., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2017; 103 (11): 818-826
Abstract

To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.

View details for DOI 10.1136/heartjnl-2016-309266

View details for Web of Science ID 000401028400006
Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194
Abstract

Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

View details for DOI 10.1111/ppe.12349

View details for Web of Science ID 000400170000004

View details for PubMedID 28328031
Assessment of a Revised Wartime Experiences Scale for Vietnam-Era Women: The Health of Vietnam-Era Women's Study (HealthViEWS). Women's health issues : official publication of the Jacobs Institute of Women's Health Sternke, L. M., Serpi, T., Spiro, A., Kimerling, R., Kilbourne, A. M., Cypel, Y., Frayne, S. M., Furey, J., Huang, G. D., Reinhard, M. J., Magruder, K. 2017
Abstract

Few wartime experiences scales capture unique issues related to women's service, address their military roles, or have been validated with women. The Women's Wartime Stressor Scale was developed for use with women who served during the Vietnam era, primarily as nurses in Vietnam. We revised this measure by modifying existing items, adding new items, and revising response formats to create a scale less nursing specific and nondeployment specific, and conducted a preliminary assessment of the revised scale.The Women's Wartime Exposure Scale-Revised (WWES-R) was included in a mail survey as part of the U.S. Department of Veterans Affairs Health of Vietnam-Era Women's Study (HealthViEWS) study. Construct and criterion validity, and internal consistency, were assessed with a sample of 4,839 women veterans using exploratory factor analysis, analysis of variance, and multiple linear regression.Six wartime experience factors consistent with previous research were identified and scales were created based on salient item loadings. Compared with women serving in the United States, women serving in Vietnam had higher mean scores on all scales, and nurses had significantly higher scores on three scales than non-nurses.Evaluation of the WWES-R suggests service and/or deployment location and service in a military health care versus a non-health care role may predict women veterans' reports of certain wartime experiences. Further psychometric evaluation of the WWES-R is recommended with later era veterans and through comparisons to other wartime exposure measures.

View details for DOI 10.1016/j.whi.2017.03.006

View details for PubMedID 28438646
The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans. Journal of general internal medicine Breland, J. Y., Phibbs, C. S., Hoggatt, K. J., Washington, D. L., Lee, J., Haskell, S., Uchendu, U. S., Saechao, F. S., Zephyrin, L. C., Frayne, S. M. 2017
Abstract

Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services.To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients.Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant.Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients).We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations.Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%).Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

View details for DOI 10.1007/s11606-016-3962-1

View details for PubMedID 28271422

View details for PubMedCentralID PMC5359156
A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration. Journal of general internal medicine Funk, L. M., Gunnar, W., Dominitz, J. A., Eisenberg, D., Frayne, S., Maggard-Gibbons, M., Kalarchian, M. A., Livingston, E., Sanchez, V., Smith, B. R., WEIDENBACHER, H., Maciejewski, M. L. 2017
Abstract

In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.

View details for DOI 10.1007/s11606-016-3951-4

View details for PubMedID 28271434

View details for PubMedCentralID PMC5359154
Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., Smelson, D., Harris, A. H., Frayne, S. M., Bowe, T., Timko, C. 2017; 44 (2): 177-187
View details for DOI 10.1007/s10488-015-0708-z

View details for Web of Science ID 000394364200004
Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study) AMERICAN JOURNAL OF CARDIOLOGY Hellyer, J. A., Azarbal, F., Than, C. T., Fan, J., Schmitt, S. K., Yang, F., Frayne, S. M., Phibbs, C. S., Yong, C., Heidenreich, P. A., Turakhia, M. P. 2017; 119 (2): 268-274
Abstract

Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.

View details for DOI 10.1016/j.amjcard.2016.09.045

View details for PubMedID 27836133
Racial And Ethnic Disparities Persist At Veterans Health Administration Patient-Centered Medical Homes. Health affairs (Project Hope) Washington, D. L., Steers, W. N., Huynh, A. K., Frayne, S. M., Uchendu, U. S., Riopelle, D., Yano, E. M., Saechao, F. S., Hoggatt, K. J. 2017; 36 (6): 1086–94
Abstract

Patient-centered medical homes are widely promoted as a primary care delivery model that achieves better patient outcomes. It is unknown if their benefits extend equally to all racial/ethnic groups. In 2010 the Veterans Health Administration, part of the Department of Veterans Affairs (VA), began implementing patient-centered medical homes nationwide. In 2009 significant disparities in hypertension or diabetes control were present for most racial/ethnic groups, compared with whites. In 2014 hypertension disparities were similar for blacks, had become smaller but remained significant for Hispanics, and were no longer significant for multiracial veterans, whereas disparities had become significant for American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. By contrast, in 2014 diabetes disparities were similar for American Indians/Alaska Natives, blacks, and Hispanics, and were no longer significant for Native Hawaiians/other Pacific Islanders. We found that the modest benefits of the VA's implementation of patient-centered medical homes were offset by competing multifactorial external, health system, provider, and patient factors, such as increased patient volume. To promote health equity, health care innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Evaluations of patient-centered medical homes should monitor outcomes for racial/ethnic groups.

View details for PubMedID 28583968
Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease. Heart Yang, F., Hellyer, J. A., Than, C., Ullal, A. J., Kaiser, D. W., Heidenreich, P. A., Hoang, D. D., Winkelmayer, W. C., Schmitt, S., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2016
Abstract

To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.

View details for DOI 10.1136/heartjnl-2016-309266

View details for PubMedID 27852694
Prevalence and risk of fracture diagnoses in women across the adult life span: a national cross-sectional study. Osteoporosis international Chang, P. Y., Saechao, F. S., Lee, J., Haskell, S. G., Frayne, S. M., Lee, J. S. 2016; 27 (11): 3177-3186
Abstract

In a national sample of women veterans, the rate of lower limb fracture diagnosis was the highest across ages 18-74 years; rates of fracture diagnosis of other skeletal sites peaked in women aged 75+. Women with two or more primary care visits or mental healthcare visits had elevated odds of fracture diagnosis.We assessed the prevalence and healthcare utilization characteristics associated with a diagnosis of any fracture in women of all adult ages within the Veterans Health Administration.In 344,488 women during fiscal year 2012, logistic regression models for fracture diagnosis included age, race/ethnicity, residence, number of primary care visits, number of mental healthcare visits, and degree of service-connected disability.Lower limb fracture diagnosis was most prevalent across ages 18-74 years and peaked in women aged 55-64 years. In women aged 75+, the prevalence rates of fracture diagnosis at the hip (102, 95 % CI = 88-115 per 10,000 women), upper limb (100, 95 % CI = 87-114 per 10,000 women), and lower limb (84, 95 % CI = 72-97 per 10,000 women) were the highest. Fractures at other skeletal sites peaked in those aged 75+ years. Black women had the lowest odds of a fracture diagnosis, followed by Asian/Pacific Islander and Hispanic women compared to non-Hispanic White (by 25-51 %, P < 0.05). Having two or more primary care visits or any mental health visit was each associated with an increased risk. Women with five or more primary care visits had a 3.36-fold (95 % CI = 3.02-3.75) greater odds than those with no such visit, and separately, women with five or more mental health visits had a 1.51-fold (95 % CI = 1.43-1.60) greater odds. Women with a fracture diagnosis had higher overall healthcare costs than those without (P < 0.001).Prevalence of fracture diagnosis differed by age, race/ethnicity, and skeletal site of fracture. Fracture diagnosis may identify women veterans with greater overall healthcare needs.

View details for PubMedID 27349559
Prevalence and risk of fracture diagnoses in women across the adult life span: a national cross-sectional study. Osteoporosis international Chang, P. Y., Saechao, F. S., Lee, J., Haskell, S. G., Frayne, S. M., Lee, J. S. 2016; 27 (11): 3177-3186
Abstract

In a national sample of women veterans, the rate of lower limb fracture diagnosis was the highest across ages 18-74 years; rates of fracture diagnosis of other skeletal sites peaked in women aged 75+. Women with two or more primary care visits or mental healthcare visits had elevated odds of fracture diagnosis.We assessed the prevalence and healthcare utilization characteristics associated with a diagnosis of any fracture in women of all adult ages within the Veterans Health Administration.In 344,488 women during fiscal year 2012, logistic regression models for fracture diagnosis included age, race/ethnicity, residence, number of primary care visits, number of mental healthcare visits, and degree of service-connected disability.Lower limb fracture diagnosis was most prevalent across ages 18-74 years and peaked in women aged 55-64 years. In women aged 75+, the prevalence rates of fracture diagnosis at the hip (102, 95 % CI = 88-115 per 10,000 women), upper limb (100, 95 % CI = 87-114 per 10,000 women), and lower limb (84, 95 % CI = 72-97 per 10,000 women) were the highest. Fractures at other skeletal sites peaked in those aged 75+ years. Black women had the lowest odds of a fracture diagnosis, followed by Asian/Pacific Islander and Hispanic women compared to non-Hispanic White (by 25-51 %, P < 0.05). Having two or more primary care visits or any mental health visit was each associated with an increased risk. Women with five or more primary care visits had a 3.36-fold (95 % CI = 3.02-3.75) greater odds than those with no such visit, and separately, women with five or more mental health visits had a 1.51-fold (95 % CI = 1.43-1.60) greater odds. Women with a fracture diagnosis had higher overall healthcare costs than those without (P < 0.001).Prevalence of fracture diagnosis differed by age, race/ethnicity, and skeletal site of fracture. Fracture diagnosis may identify women veterans with greater overall healthcare needs.

View details for PubMedID 27349559
Receptivity to alcohol-related care among U.S. women Veterans with alcohol misuse. Journal of addictive diseases Lewis, E. T., Jamison, A. L., Ghaus, S., Durazo, E. M., Frayne, S. M., Hoggatt, K. J., Bean-Mayberry, B., Timko, C., Cucciare, M. A. 2016; 35 (4): 226-237
Abstract

Previous research indicates women Veterans have a potentially large, unmet need for alcohol-related care but are under-represented in treatment settings. The purpose of this study was to identify factors associated with women Veterans' receptivity to a recommendation for alcohol-related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. Semi-structured interviews were conducted from 2012-2013 with 30 women Veterans at two VA facilities who screened positive for alcohol misuse during a primary care visit and discussed their alcohol use with their primary-care provider. Qualitative analyses identified 9 themes women used to describe what affected their receptivity to a recommendation for alcohol-related care (i.e., VA specialty substance use disorder services). The most common themes positively associated with women's receptivity included self-appraisal of their drinking behavior as more severe, the provider's presentation of treatment options, availability of gender-specific services, and worse physical and mental health. The themes identified here may have important implications for the clinical strategies providers can use to present alcohol-related care options to women Veterans to facilitate their use of care. These strategies include educating women about the health effects of alcohol misuse and increasing providers' knowledge about available care options (within the care organization or the community), including the availability of gender-specific services.

View details for PubMedID 27049338
Race and Gender Differences in the Use of Direct Acting Antiviral Agents for Hepatitis C Virus CLINICAL INFECTIOUS DISEASES Kanwal, F., Kramer, J. R., El-Serag, H. B., Frayne, S., Clark, J., Cao, Y., Taylor, T., Smith, D., White, D., Asch, S. M. 2016; 63 (3): 291-299
Abstract

Direct acting antiviral agents (DAA) are highly effective yet expensive. Disparities by race and/or gender often exist in the use of costly medical advances as they become available.We examined a cohort of hepatitis C virus (HCV) patients who received care at the Veterans Administration facilities nationwide. We evaluated the effect of race and gender on DAA receipt after adjusting for socioeconomic status, liver disease severity, comorbidity, and propensity for healthcare use. To determine if disparities had changed over time, we conducted a similar analysis of HCV patients who were seen in the previous standard of care treatment era.Of the 145 596 patients seen in the current DAA era, 17 791 (10.2%) received treatment during the first 16 months of DAA approval. Black patients had 21% lower odds of receiving DAA than whites (odds ratio [OR] = 0.79; 95% confidence interval [CI], .75, .84). Overall, women were as likely to receive treatment as men (OR = 0.99; 95% CI, .90-1.09). However, the odds of receiving DAAs were 29% lower for younger women compared with younger men (OR = 0.71, 95% CI, .54-.93). Similar to the DAA cohort, black patients had significantly lower odds of receiving treatment than whites (OR = 0.74, 95% CI, .69-.79) in the previous treatment era. The racial difference between the 2 eras did not reach statistical significance.There were unexplained differences among HCV population subgroups in the receipt of new DAA treatment. Targeted interventions are needed for black patients and younger women.

View details for DOI 10.1093/cid/ciw249

View details for Web of Science ID 000383201900001

View details for PubMedID 27131869
Binge Eating among Women Veterans in Primary Care: Comorbidities and Treatment Priorities. Women's health issues : official publication of the Jacobs Institute of Women's Health Rosenbaum, D. L., Kimerling, R., Pomernacki, A., Goldstein, K. M., Yano, E. M., Sadler, A. G., Carney, D., Bastian, L. A., Bean-Mayberry, B. A., Frayne, S. M. 2016; 26 (4): 420-428
Abstract

Little is known about the clinical profile and treatment priorities of women with binge eating disorder (BED), a diagnosis new to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders. We identified comorbidities and patients' treatment priorities, because these may inform implementation of clinical services.Data were collected from women veteran primary care patients. Analyses compared those who screened positive for BED (BED+), and those without any binge eating symptoms (BED-).Frequencies of comorbid medical and psychological disorders were high in the BED+ group. The BED+ group's self-identified most common treatment priorities were mood concerns (72.2%), weight loss (66.7%), and body image/food issues (50%). Among those with obesity, a greater proportion of the BED+ group indicated body image/food issues was their top treatment priority (12.9% vs. 2.8%; p < .01), suggesting that these patients may be more apt to seek treatment beyond weight management for their problematic eating patterns.Women primary care patients with BED demonstrate high medical and psychological complexity; their subjective treatment priorities often match objective needs. These findings may inform the development of targeted BED screening practices for women with obesity in primary care settings, and the eventual adoption of patient-centered BED treatment resources.

View details for DOI 10.1016/j.whi.2016.02.004

View details for PubMedID 26972486
Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program. journal of continuing education in the health professions Fox, A. B., Hamilton, A. B., Frayne, S. M., Wiltsey-Stirman, S., Bean-Mayberry, B., Carney, D., Di Leone, B. A., Gierisch, J. M., Goldstein, K. M., Romodan, Y., Sadler, A. G., Yano, E. M., Yee, E. F., Vogt, D. 2016; 36 (2): 96-103
Abstract

Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation.Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation.Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified.Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.

View details for DOI 10.1097/CEH.0000000000000073

View details for PubMedID 27262152
Receipt of pharmacotherapy for opioid use disorder by justice-involved U.S. Veterans Health Administration patients. Drug and alcohol dependence Finlay, A. K., Harris, A. H., Rosenthal, J., Blue-Howells, J., Clark, S., McGuire, J., Timko, C., Frayne, S. M., Smelson, D., Oliva, E., Binswanger, I. 2016; 160: 222-226
Abstract

Pharmacotherapy - methadone, buprenorphine, or naltrexone - is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement.Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics.The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65-0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds.Targeted efforts to improve receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications.

View details for DOI 10.1016/j.drugalcdep.2016.01.013

View details for PubMedID 26832998

View details for PubMedCentralID PMC4767599
Factors Affecting Women's Disclosure of Alcohol Misuse in Primary Care: A Qualitative Study with US Military Veterans WOMENS HEALTH ISSUES Cucciare, M. A., Lewis, E. T., Hoggatt, K. J., Bean-Mayberry, B., Timko, C., Durazo, E. M., Jamison, A. L., Frayne, S. M. 2016; 26 (2): 232-239
Abstract

One in five women veterans screens positive for alcohol misuse. Women may be less likely than men to disclose alcohol use to a primary care provider (PCP), resulting in women being less likely to receive effective interventions. We sought to qualitatively examine factors that may affect women veterans' willingness to disclose alcohol use to a PCP.Between October 2012 and May 2013, in-depth interviews were conducted with 30 women veterans at two Department of Veterans Affairs (VA) medical facilities. Qualitative data analyses identified common themes representing factors that influence women's decision to disclose alcohol use to a PCP.Nine themes were endorsed by women veterans as influencing their willingness to disclose alcohol use to their PCP. Themes included provider behaviors perceived as encouraging or discouraging disclosure of alcohol misuse, perceived positive relationship with provider, negative emotions such as concerns about being judged or labeled an "alcoholic," health concerns about drinking, non-health-related concerns about drinking, self-appraisal of drinking behavior, social support, and clinic factors.Our findings demonstrate the importance of social relationships, comfort with one's provider, and education on the potential harms (especially health related) associated with alcohol in encouraging disclosure of alcohol use in women veterans. Our results also support VA national health care efforts, including the provision of brief alcohol counseling and the use of primary care clinics specializing in the care of women veterans.

View details for DOI 10.1016/j.whi.2015.07.010

View details for Web of Science ID 000375058000015

View details for PubMedID 26341569
Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study) AMERICAN JOURNAL OF CARDIOLOGY Yong, C., Azarbal, F., Abnousi, F., Heidenreich, P. A., Schmitt, S., Fan, J., Than, C. T., Ullal, A. J., Yang, F., Phibbs, C. S., Frayne, S. M., Ho, P. M., Shore, S., Mahaffey, K. W., Turakhia, M. P. 2016; 117 (1): 61-68
Abstract

The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.

View details for DOI 10.1016/j.amjcard.2015.09.047

View details for Web of Science ID 000368048900010
Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study). The American journal of cardiology Yong, C., Azarbal, F., Abnousi, F., Heidenreich, P. A., Schmitt, S., Fan, J., Than, C. T., Ullal, A. J., Yang, F., Phibbs, C. S., Frayne, S. M., Ho, P. M., Shore, S., Mahaffey, K. W., Turakhia, M. P. 2016; 117 (1): 61–68
Abstract

The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.

View details for PubMedID 26552504
Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program. Administration and policy in mental health Finlay, A. K., Stimmel, M., Blue-Howells, J., Rosenthal, J., McGuire, J., Binswanger, I., Smelson, D., Harris, A. H., Frayne, S. M., Bowe, T., Timko, C. 2015: -?
Abstract

The Veterans Health Administration (VA) Health Care for Reentry Veterans (HCRV) program links veterans exiting prison with treatment. Among veterans served by HCRV, national VA clinical data were used to describe contact with VA health care, and mental health and substance use disorder diagnoses and treatment use. Of veterans seen for an HCRV outreach visit, 56 % had contact with VA health care. Prevalence of mental health disorders was 57 %; of whom 77 % entered mental health treatment within a month of diagnosis. Prevalence of substance use disorders was 49 %; of whom 37 % entered substance use disorder treatment within a month of diagnosis. For veterans exiting prison, increasing access to VA health care, especially for rural veterans, and for substance use disorder treatment, are important quality improvement targets.

View details for PubMedID 26687114
Appropriate Screening for Substance Use vs Disorder Reply JAMA INTERNAL MEDICINE Tiet, Q. Q., Moos, R. H., Frayne, S. M. 2015; 175 (12): 1998–99
View details for PubMedID 26641357
Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study. American heart journal Ullal, A. J., Than, C. T., Fan, J., Schmitt, S., Perino, A. C., Kaiser, D. W., Heidenreich, P. A., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2015; 170 (5): 1033-1041 e1
Abstract

There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.

View details for DOI 10.1016/j.ahj.2015.07.023

View details for PubMedID 26542514

View details for PubMedCentralID PMC4800972
Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study AMERICAN HEART JOURNAL Ullal, A. J., Than, C. T., Fan, J., Schmitt, S., Perino, A. C., Kaiser, D. W., Heidenreich, P. A., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2015; 170 (5): 1033-U231
Abstract

There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.

View details for DOI 10.1016/j.ahj.2015.07.023

View details for Web of Science ID 000364434600026

View details for PubMedID 26542514

View details for PubMedCentralID PMC4800972
Prevalence of Posttraumatic Stress Disorder in Vietnam-Era Women Veterans The Health of Vietnam-Era Women's Study (HealthVIEWS) JAMA PSYCHIATRY Magruder, K., Serpi, T., Kimerling, R., Kilbourne, A. M., Collins, J. F., Cypel, Y., Frayne, S. M., Furey, J., Huang, G. D., Gleason, T., Reinhard, M. J., Spiro, A., Kang, H. 2015; 72 (11): 1127-1134
View details for DOI 10.1001/jamapsychiatry.2015.1786

View details for PubMedID 26445103
Anticoagulation in Atrial Fibrillation: Impact of Mental Illness AMERICAN JOURNAL OF MANAGED CARE Schmitt, S. K., Turakhia, M. P., Phibbs, C. S., Moos, R. H., Berlowitz, D., Heidenreich, P., Chiu, V. Y., Go, A. S., Friedman, S. A., Than, C. T., Frayne, S. M. 2015; 21 (11): E609-E617
Abstract

To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).Retrospective cohort study.This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

View details for Web of Science ID 000379911700003

View details for PubMedID 26735294
Lessons from Initiating the First Veterans Health Administration (VA) Women's Health Practice-based Research Network (WH-PBRN) Study. Journal of the American Board of Family Medicine Pomernacki, A., Carney, D. V., Kimerling, R., Nazarian, D., Blakeney, J., Martin, B. D., Strehlow, H., Yosef, J., Goldstein, K. M., Sadler, A. G., Bean-Mayberry, B. A., Bastian, L. A., Bucossi, M. M., McLean, C., Sonnicksen, S., Klap, R., Yano, E. M., Frayne, S. M. 2015; 28 (5): 649-657
Abstract

The Veterans Health Administration (VA) Women's Health Practice-Based Research Network (WH-PBRN) was created to foster innovations for the health care of women veterans. The inaugural study by the WH-PBRN was designed to identify women veterans' own priorities and preferences for mental health services and to inform refinements to WH-PBRN operational procedures. Addressing the latter, this article reports lessons learned from the inaugural study.WH-PBRN site coordinators at the 4 participating sites convened weekly with the study coordinator and the WH-PBRN program manager to address logistical issues and identify lessons learned. Findings were categorized into a matrix of challenges and facilitators related to key study elements.Challenges to the conduct of PBRN-based research included tracking of regulatory documents; cross-site variability in some regulatory processes; and troubleshooting logistics of clinic-based recruitment. Facilitators included a central institutional review board, strong relationships between WH-PBRN research teams and women's health clinic teams, and the perception that women want to help other women veterans.Our experience with the inaugural WH-PBRN study demonstrated the feasibility of establishing productive relationships between local clinicians and researchers, and of recruiting a special population (women veterans) in diverse sites within an integrated health care system. This identified strengths of a PBRN approach.

View details for DOI 10.3122/jabfm.2015.05.150029

View details for PubMedID 26355137
Screen of Drug Use: Diagnostic Accuracy of a New Brief Tool for Primary Care. JAMA internal medicine Tiet, Q. Q., Leyva, Y. E., Moos, R. H., Frayne, S. M., Osterberg, L., Smith, B. 2015; 175 (8): 1371-1377
Abstract

Illicit drug use is prevalent, and primary care provides an ideal setting in which to screen for drug use disorders (DUDs) and negative consequences of drug use (NCDU). Comprehensive reviews have concluded that existing drug use screening instruments are not appropriate for routine use in primary care.To develop and validate a screening instrument for drug use.We revised items drawn from existing screening instruments and conducted signal detection analyses to develop the new instrument. We approached 3173 patients at 2 primary care clinics in a US Department of Veterans Affairs health care system from February 1, 2012, through April 30, 2014. A total of 1300 (41.0%) patients consented to the study, of whom 1283 adults were eligible (mean [SD] age, 62.2 [12.6] years). In the last 12 months, 241 (18.8%) participants reported using illicit drugs or prescription medication for a nonmedical purpose, and 189 (14.7%) reported 1 or more NCDU. A total of 133 (10.4%) patients met DSM-IV criteria for a DUD. The sample was randomly divided first to develop the measure and then to validate it.The Mini-International Diagnostic Interview was used as the criterion for DUDs, and the Inventory of Drug Use Consequences was used as the criterion for NCDU.The screening instrument has 2 questions. The first is, "How many days in the past 12 months have you used drugs other than alcohol?" Patients meet that criterion with a response of 7 or more days. The second question asks, "How many days in the past 12 months have you used drugs more than you meant to?" A response of 2 or more days meets that criterion. The screening instrument was 100% sensitive and 93.73% specific for DUDs (643 patients); when replicated in the second half of the sample (640 patients), it was 92.31% sensitive and 92.87% specific. The screening instrument was 93.18% sensitive and 96.03% specific for NCDU (643 patients); when replicated in the second half of the sample (640 patients), it was 83.17% sensitive and 96.85% specific.The 2-item screen of drug use has excellent statistical properties and is a brief screening instrument for DUDs and problems suitable for busy US Department of Veterans Affairs primary care clinics.

View details for DOI 10.1001/jamainternmed.2015.2438

View details for PubMedID 26075352
Sex Differences in Mental Health and Substance Use Disorders and Treatment Entry Among Justice-involved Veterans in the Veterans Health Administration. Medical care Finlay, A. K., Binswanger, I. A., Smelson, D., Sawh, L., McGuire, J., Rosenthal, J., Blue-Howells, J., Timko, C., Blodgett, J. C., Harris, A. H., Asch, S. M., Frayne, S. 2015; 53 (4): S105-11
Abstract

Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.A total of 1535 females and 30,478 male veterans were included.Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

View details for DOI 10.1097/MLR.0000000000000271

View details for PubMedID 25767963
In reply. Obstetrics and gynecology Shaw, J. G., Asch, S. M., Frayne, S. M., Phibbs, C. S., Kimerling, R., Shaw, K. A. 2015; 125 (4): 989-?
View details for DOI 10.1097/AOG.0000000000000783

View details for PubMedID 25798980
Readying the Workforce: Evaluation of VHA's Comprehensive Women's Health Primary Care Provider Initiative. Medical care Maisel, N. C., Haskell, S., Hayes, P. M., Balasubramanian, V., Torgal, A., Ananth, L., Saechao, F., Iqbal, S., Phibbs, C. S., Frayne, S. M. 2015; 53 (4): S39-46
Abstract

Veterans Health Administration (VHA) primary care providers (PCPs) often see few women, making it challenging to maintain proficiency in women's health (WH). Therefore, VHA in 2010 established Designated WH Providers, who would maintain proficiency in comprehensive WH care and be preferentially assigned women patients.To evaluate early implementation of this national policy.At each VHA health care system (N=140), the Women Veterans Program Manager completed a Fiscal Year 2012 workforce capacity assessment (response rate, 100%), representing the first time the national Designated WH Provider workforce had been identified. Assessment data were linked to administrative data.Of all VHA PCPs, 23% were Designated WH Providers; 100% of health care systems and 83% of community clinics had at least 1 Designated WH Provider. On average, women veterans comprised 19% (SD=27%) of the patients Designated WH Providers saw in primary care, versus 5% (SD=7%) for Other PCPs (P<0.001). For women veterans using primary care (N=313,033), new patients were less likely to see a Designated WH Provider than established women veteran patients (52% vs. 64%; P<0.001).VHA has achieved its goal of a Designated WH Provider in every health care system, and is approaching its goal of a Designated WH Provider at every hospital/community clinic. Designated WH Providers see more women than do Other PCPs. However, as the volume of women patients remains low for many providers, attention to alternative approaches to maintaining proficiency may prove necessary, and barriers to assigning new women patients to Designated WH Providers merit attention.

View details for DOI 10.1097/MLR.0000000000000298

View details for PubMedID 25767974
Reproductive health diagnoses of women veterans using department of veterans affairs health care. Medical care Katon, J. G., Hoggatt, K. J., Balasubramanian, V., Saechao, F. S., Frayne, S. M., Mattocks, K. M., Feibus, K. B., Galvan, I. V., Hickman, R., Hayes, P. M., Haskell, S. G., Yano, E. M., Phibbs, C. S., Zephyrin, L. C. 2015; 53 (4): S63-7
Abstract

Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care.To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses.This study is a cross-sectional analysis of VA administrative and clinical data.The study included women Veterans using VA health care in FY10.Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, ≥65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis.The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged ≥65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001).Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.

View details for DOI 10.1097/MLR.0000000000000295

View details for PubMedID 25767978
Travel Time and Attrition From VHA Care Among Women Veterans: How Far is Too Far? Medical care Friedman, S. A., Frayne, S. M., Berg, E., Hamilton, A. B., Washington, D. L., Saechao, F., Maisel, N. C., Lin, J. Y., Hoggatt, K. J., Phibbs, C. S. 2015; 53 (4): S15-22
Abstract

Travel time, an access barrier, may contribute to attrition of women veterans from Veterans Health Administration (VHA) care.We examined whether travel time influences attrition: (a) among women veterans overall, (b) among new versus established patients, and (c) among rural versus urban patients.This retrospective cohort study used logistic regression to estimate the association between drive time and attrition, overall and for new/established and rural/urban patients.In total, 266,301 women veteran VHA outpatients in the Fiscal year 2009.An "attriter" did not return for VHA care during the second through third years after her first 2009 visit (T0). Drive time (log minutes) was between the patient's residence and her regular source of VHA care. "New" patients had no VHA visits within 3 years before T0. Models included age, service-connected disability, health status, and utilization as covariates.Overall, longer drive times were associated with higher odds of attrition: drive time adjusted odds ratio=1.11 (99% confidence interval, 1.09-1.14). The relationship between drive time and attrition was stronger among new patients but was not modified by rurality.Attrition among women veterans is sensitive to longer drive time. Linking new patients to VHA services designed to reduce distance barriers (telemedicine, community-based clinics, mobile clinics) may reduce attrition among women new to VHA.

View details for DOI 10.1097/MLR.0000000000000296

View details for PubMedID 25767970

View details for PubMedCentralID PMC4386926
Patient-centered mental health care for female veterans. Psychiatric services Kimerling, R., Bastian, L. A., Bean-Mayberry, B. A., Bucossi, M. M., Carney, D. V., Goldstein, K. M., Phibbs, C. S., Pomernacki, A., Sadler, A. G., Yano, E. M., Frayne, S. M. 2015; 66 (2): 155-162
Abstract

Mental health services for women vary widely across the Veterans Health Administration (VHA) system, without consensus on the need for, or organization of, specialized services for women. Understanding women's needs and priorities is essential to guide the implementation of patient-centered behavioral health services.In a cross-sectional, multisite survey of female veterans using primary care, potential stakeholders were identified for VHA mental health services by assessing perceived or observed need for mental health services. These stakeholders (N=484) ranked priorities for mental health care among a wide range of possible services. The investigators then quantified the importance of having designated women's mental health services for each of the mental health services that emerged as key priorities.Treatment for depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and posttraumatic stress disorder (PTSD) emerged as women's key priorities. Having mental health services specialized for women was rated as extremely important to substantial proportions of women for each of the six prioritized services. Preference for primary care colocation was strongly associated with higher importance ratings for designated women's mental health services. For specific types of services, race, ethnicity, sexual orientation, PTSD symptoms, and psychiatric comorbidity were also associated with higher importance ratings for designated women's services.Female veterans are a diverse population whose needs and preferences for mental health services vary along demographic and clinical factors. These stakeholder perspectives can help prioritize structural and clinical aspects of designated women's mental health care in the VHA.

View details for DOI 10.1176/appi.ps.201300551

View details for PubMedID 25642611
Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119
Abstract

To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

View details for DOI 10.1097/AOG.0000000000000542

View details for Web of Science ID 000345341100008
Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstetrics and gynecology Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119
Abstract

To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

View details for DOI 10.1097/AOG.0000000000000542

View details for PubMedID 25415162
Mental illness and intensification of diabetes medications: an observational cohort study BMC HEALTH SERVICES RESEARCH Frayne, S. M., Holmes, T. H., Berg, E., Goldstein, M. K., Berlowitz, D. R., Miller, D. R., Pogach, L. M., Laungani, K. J., Lee, T. T., Moos, R. 2014; 14
Abstract

Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status.Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.

View details for DOI 10.1186/1472-6963-14-458

View details for Web of Science ID 000343734700001

View details for PubMedCentralID PMC4282515
Antiobesity Medication Use Across the Veterans Health Administration: Patient-Level Predictors of Receipt OBESITY Del Re, A. C., Frayne, S. M., Harris, A. H. 2014; 22 (9): 1968-1972
Abstract

Pharmacotherapy is an effective adjunct to behavioral interventions to treat obesity; although it is unclear how often medications are integrated into obesity treatment plans and for which patients in the Veterans Health Administration (VHA).A retrospective cohort study was conducted that examined variation in and predictors of antiobesity medication receipt (orlistat) among > 2 million obese Veterans within 140 facilities nationwide.One-percent of all obese patients using VHA services filled a prescription for orlistat. Veterans were more likely to be treated with orlistat if they had a higher BMI, were female, unmarried, younger, a minority, had home instability, prescribed obesogenic psychiatric medications, had a psychiatric or obesity-related comorbidity, and used MOVE! weight management services. Among those who likely met the criteria for use, 2.5% had at least one orlistat prescription. Facility-level prescription rates varied from 0 to 1% of all obese patients in a VA facility receiving a prescription and 0 to 21% among those who met the criteria for use.Consistent with guidelines recommending that obesity pharmacotherapy be prescribed in conjunction with behavioral therapy, the strongest predictor of receiving orlistat was being enrolled in the MOVE! weight-loss management program.

View details for DOI 10.1002/oby.20810

View details for Web of Science ID 000341578000008

View details for PubMedID 24931332
Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation: Findings From the TREAT-AF Study. Journal of the American College of Cardiology Turakhia, M. P., Santangeli, P., Winkelmayer, W. C., Xu, X., Ullal, A. J., Than, C. T., Schmitt, S., Holmes, T. H., Frayne, S. M., Phibbs, C. S., Yang, F., Hoang, D. D., Ho, P. M., Heidenreich, P. A. 2014; 64 (7): 660-668
Abstract

Despite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in atrial fibrillation/flutter (AF).The goal of this study was to evaluate the association of digoxin with mortality in AF.Using complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual confounding was assessed by sensitivity analysis.Of 122,465 patients with 353,168 person-years of follow-up (age 72.1 ± 10.3 years, 98.4% male), 28,679 (23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated patients (95 vs. 67 per 1,000 person-years; p < 0.001). Digoxin use was independently associated with mortality after multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, p < 0.001) and propensity matching (HR: 1.21, 95% CI: 1.17 to 1.25, p < 0.001), even after adjustment for drug adherence. The risk of death was not modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin.Digoxin was associated with increased risk of death in patients with newly diagnosed AF, independent of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge current cardiovascular society recommendations on use of digoxin in AF.

View details for DOI 10.1016/j.jacc.2014.03.060

View details for PubMedID 25125296
Diagnostic Accuracy of the Composite International Diagnostic Interview (CIDI 3.0) PTSD Module Among Female Vietnam-Era Veterans. Journal of traumatic stress Kimerling, R., Serpi, T., Weathers, F., Kilbourne, A. M., Kang, H., Collins, J. F., Cypel, Y., Frayne, S. M., Furey, J., Huang, G. D., Reinhard, M. J., Spiro, A., Magruder, K. 2014; 27 (2): 160-167
Abstract

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam-era veterans. The CIDI and the Clinician-Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3-week interval. Forty-five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past-year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past-year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.

View details for DOI 10.1002/jts.21905

View details for PubMedID 24740869
HealthViEWS: Mortality Study of Female US Vietnam Era Veterans, 1965-2010. American journal of epidemiology Kang, H. K., Cypel, Y., Kilbourne, A. M., Magruder, K. M., Serpi, T., Collins, J. F., Frayne, S. M., Furey, J., Huang, G. D., Kimerling, R., Reinhard, M. J., Schumacher, K., Spiro, A. 2014; 179 (6): 721-730
Abstract

We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.

View details for DOI 10.1093/aje/kwt319

View details for PubMedID 24488510
Five-year trends in women veterans' use of VA maternity benefits, 2008-2012. Women's health issues : official publication of the Jacobs Institute of Women's Health Mattocks, K. M., Frayne, S., Phibbs, C. S., Yano, E. M., Zephyrin, L., Shryock, H., Haskell, S., Katon, J., Sullivan, J. C., Weinreb, L., Ulbricht, C., Bastian, L. A. 2014; 24 (1): e37-42
Abstract

An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.We included pregnant veterans using VHA maternity benefits for delivery.Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.

View details for DOI 10.1016/j.whi.2013.10.002

View details for PubMedID 24439945
Mental illness and intensification of diabetes medications: an observational cohort study. BMC health services research Frayne, S. M., Holmes, T. H., Berg, E., Goldstein, M. K., Berlowitz, D. R., Miller, D. R., Pogach, L. M., Laungani, K. J., Lee, T. T., Moos, R. 2014; 14: 458-?
Abstract

Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type.In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status.Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value.For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.

View details for DOI 10.1186/1472-6963-14-458

View details for PubMedID 25339147
Five-year Trends in Women Veterans' Use of VA Maternity Benefits, 2008-2012. Women's health issues : official publication of the Jacobs Institute of Women's Health Mattocks, K. M., Frayne, S., Phibbs, C. S., Yano, E. M., Zephyrin, L., Shryock, H., Haskell, S., Katon, J., Sullivan, J. C., Weinreb, L., Ulbricht, C., Bastian, L. A. 2014; 24 (1): e37-42
Abstract

An increasing number of young women veterans are returning from war and military service and are seeking reproductive health care from the Veterans Health Administration (VHA). Many of these women seek maternity benefits from the VHA, and yet little is known regarding the number of women veterans utilizing VHA maternity benefits nor the characteristics of pregnant veterans using these benefits. In May 2010, VHA maternity benefits were expanded to include 7 days of infant care, which may serve to entice more women to use VHA maternity benefits. Understanding the changing trends in women veterans seeking maternity benefits will help the VHA to improve the quality of reproductive care over time.The goal of this study was to examine the trends in delivery claims among women veterans receiving VHA maternity benefits over a 5-year period and the characteristics of pregnant veterans utilizing VHA benefits.We undertook a retrospective, national cohort study of pregnant veterans enrolled in VHA care with inpatient deliveries between fiscal years (FY) 2008 and 2012.We included pregnant veterans using VHA maternity benefits for delivery.Measures included annualized numbers and rates of inpatient deliveries and delivery-related costs, as well as cesarean section rates as a quality indicator.During the 5-year study period, there was a significant increase in the number of deliveries to women veterans using VHA maternity benefits. The overall delivery rate increased by 44% over the study period from 12.4 to 17.8 deliveries per 1,000 women veterans. A majority of women using VHA maternity benefits were age 30 or older and had a service-connected disability. From FY 2008 to 2012, the VHA paid more than $46 million in delivery claims to community providers for deliveries to women veterans ($4,993/veteran).Over a 5-year period, the volume of women veterans using VHA maternity benefits increased by 44%. Given this sizeable increase, the VHA must increase its capacity to care for pregnant veterans and ensure care coordination systems are in place to address the needs of pregnant veterans with service-connected disabilities.

View details for DOI 10.1016/j.whi.2013.10.002

View details for PubMedID 24439945
Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans JOURNAL OF GENERAL INTERNAL MEDICINE Hamilton, A. B., Frayne, S. M., Cordasco, K. M., Washington, D. L. 2013; 28: S510-S516
Abstract

While prior research characterizes women Veterans' barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.Cross-sectional, population-based 2008-2009 national telephone survey.Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.We found high VA attrition despite recent advances in VA care for women Veterans. Women's attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.

View details for DOI 10.1007/s11606-013-2347-y

View details for Web of Science ID 000321910900006

View details for PubMedID 23807058
Receipt of cervical cancer screening in female veterans: impact of posttraumatic stress disorder and depression. Women's health issues : official publication of the Jacobs Institute of Women's Health Weitlauf, J. C., Jones, S., Xu, X., Finney, J. W., Moos, R. H., Sawaya, G. F., Frayne, S. M. 2013; 23 (3): e153-9
Abstract

We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration facilities between 2003 and 2007 and diagnosed with 1) posttraumatic stress disorder (PTSD), or 2) depression, or 3) no psychiatric illness.Our study featured a cross-sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups.Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD versus 75% with depression versus 75% without psychiatric illness were screened during the study observation period (p < .001). However, primary care use was associated with differential odds of screening in women with versus without psychiatric illness (PTSD or depression), even after adjustment for age, income and physical comorbidities (Wald Chi-square (2): 126.59; p < .0001). Specifically, among low users of primary care services, women with PTSD or depression were more likely than those with no psychiatric diagnoses to receive screening. Among high users of primary care services, they were less likely to receive screening.Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with versus without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive healthcare needs.

View details for DOI 10.1016/j.whi.2013.03.002

View details for PubMedID 23660429
A Randomized Controlled Trial of a Web-Delivered Brief Alcohol Intervention in Veterans Affairs Primary Care JOURNAL OF STUDIES ON ALCOHOL AND DRUGS Cucciare, M. A., Weingardt, K. R., Ghaus, S., Boden, M. T., Frayne, S. M. 2013; 74 (3): 428-436
Abstract

This study sought to examine whether a web-delivered brief alcohol intervention (BAI) is effective for reducing alcohol misuse in U.S. military veterans presenting to primary care.Veterans (N = 167) screening positive for alcohol misuse during a routine primary care visit were randomized to receive a BAI plus treatment as usual (TAU) or TAU alone. An assessment of alcohol-related outcomes was conducted at baseline and 3 and 6 months after treatment.Veterans in both study conditions showed a significant reduction in alcohol quantity and frequency and alcohol-related problems at 6-month follow-up. No differential treatment effects on outcomes were observed between the two treatment groups.This study is the first to explore whether a web-delivered BAI using normative feedback is effective for veterans with alcohol misuse. Our findings suggest that BAIs using normative feedback may not have any additional benefit beyond TAU for older veterans with high rates of comorbid mental health concerns.

View details for Web of Science ID 000316644300009

View details for PubMedID 23490572
Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study. American heart journal Turakhia, M. P., Hoang, D. D., Xu, X., Frayne, S., Schmitt, S., Yang, F., Phibbs, C. S., Than, C. T., Wang, P. J., Heidenreich, P. A. 2013; 165 (1): 93-101 e1
Abstract

Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.

View details for DOI 10.1016/j.ahj.2012.10.010

View details for PubMedID 23237139
Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study AMERICAN HEART JOURNAL Turakhia, M. P., Hoang, D. D., Xu, X., Frayne, S., Schmitt, S., Yang, F., Phibbs, C. S., Than, C. T., Wang, P. J., Heidenreich, P. A. 2013; 165 (1): 93-?
Abstract

Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.

View details for DOI 10.1016/j.ahj.2012.10.010

View details for Web of Science ID 000312272900017

View details for PubMedID 23237139
POSTTRAUMATIC STRESS DISORDER, MILITARY SEXUAL TRAUMA AND PRETERM BIRTH Western Regional Meeting of the American-Federation-for-Medical-Research Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. LIPPINCOTT WILLIAMS & WILKINS. 2013: 226–26
View details for Web of Science ID 000312657900411
The VA Women's Health Practice-Based Research Network: Amplifying Women Veterans' Voices in VA Research. Journal of general internal medicine Frayne, S. M., Carney, D. V., Bastian, L., Bean-Mayberry, B., Sadler, A., Klap, R., Phibbs, C. S., Kimerling, R., Vogt, D., Yee, E. F., Lin, J. Y., Yano, E. M. 2013; 28 Suppl 2: 504–9
View details for DOI 10.1007/s11606-013-2476-3

View details for PubMedID 23807057
Trends in Rates and Attributable Costs of Conditions among Female VA Patients, 2000 and 2008 WOMENS HEALTH ISSUES Yoon, J., Scott, J. Y., Phibbs, C. S., Frayne, S. M. 2012; 22 (3): E337-E344
Abstract

We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.

View details for DOI 10.1016/j.whi.2012.03.002

View details for Web of Science ID 000209039000012
Trends in rates and attributable costs of conditions among female VA patients, 2000 and 2008. Women's health issues : official publication of the Jacobs Institute of Women's Health Yoon, J., Scott, J. Y., Phibbs, C. S., Frayne, S. M. 2012; 22 (3): e337-44
Abstract

We examined rates of specific health conditions among female veteran patients and how the share of health care costs attributable to these conditions changed in the Veterans Affairs system between 2000 and 2008.Veterans' Administration (VA)-provided and VA-sponsored inpatient, outpatient, and pharmacy utilization and cost files were analyzed for women veterans receiving care in 2000 and 2008. We estimated rates of 42 common health conditions and per-patient condition costs from a regression model and calculated the total population costs attributable to each condition and changes by year.The number of female VA patients increased from 156,305 in 2000 to 266,978 in 2008; 88% were under 65 years of age. The rate of women treated for specific conditions increased substantially for many gender-specific and psychiatric conditions: For example, pregnancy increased 133%, diagnosed posttraumatic stress disorder increased 106%, and diagnosed depression increased 41%. Mean costs of care increased from $4,962 per woman in 2000 to $6,570 per woman in 2008. Psychiatric conditions accounted for more than one quarter of population health care costs in 2008. Gender-specific conditions and musculoskeletal diseases accounted for a rising share of population costs and rose to 8.2% and 8.7% of population costs in 2008, respectively.Gender-specific, cancer, musculoskeletal, and mental health and substance use disorders accounted for a greater share of overall costs during the study period and were primarily driven by higher rates of diagnosed conditions and, for several conditions, higher treatment costs.

View details for DOI 10.1016/j.whi.2012.03.002

View details for PubMedID 22555220
Posttraumatic stress disorder, substance use disorders, and medical comorbidity among returning U.S. veterans JOURNAL OF TRAUMATIC STRESS Nazarian, D., Kimerling, R., Frayne, S. M. 2012; 25 (2): 220-225
Abstract

Evidence suggests that posttraumatic stress disorder (PTSD) and substance use disorders (SUD) are associated with poorer physical health among U.S. veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). No research of which we are aware has examined the independent and interactive effects of PTSD and SUD on medical comorbidity among OEF/OIF veterans. This cross-sectional study examined medical record data of female and male OEF/OIF veterans with ≥ 2 Veterans Affairs primary care visits (N = 73,720). Gender-stratified logistic regression analyses, adjusted for sociodemographic factors, were used to examine the association of PTSD, SUD, and their interaction on the odds of medical diagnoses. PTSD was associated with increased odds of medical diagnoses in 9 of the 11 medical categories among both women and men, range of odds ratios (ORs) ranged from 1.07 to 2.29. Substance use disorders were associated with increased odds of 2 of the 11 medical categories among women and 3 of the 11 medical categories among men; ORs ranged from 1.20 to 1.74. No significant interactions between PTSD and SUD were detected for women or men. Overall, findings suggest that PTSD had a stronger association with medical comorbidity (in total and across various medical condition categories) than SUD among female and male OEF/OIF veterans.

View details for DOI 10.1002/jts.21690

View details for Web of Science ID 000303041500016

View details for PubMedID 22522739
Organizational factors associated with screening for military sexual trauma. Women's health issues : official publication of the Jacobs Institute of Women's Health Hyun, J. K., Kimerling, R., Cronkite, R. C., McCutcheon, S., Frayne, S. M. 2012; 22 (2): e209-15
Abstract

This exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration's (VHA) implementation of the universal MST screening policy.The sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates.Facility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39-5.89) for new female patients; OR, 8.15 (95% CI, 2.93-22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79-11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26-2.91) for females and OR, 1.86 (95% CI, 1.22-2.84) for males. Although the facility-level effect for women's health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18-2.71) for continuing patients and OR, 2.20 (95% CI, 1.59-3.04) for new patients.This study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans' utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA's MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.

View details for DOI 10.1016/j.whi.2011.09.001

View details for PubMedID 22055987
Organizational Factors Associated with Screening for Military Sexual Trauma WOMENS HEALTH ISSUES Hyun, J. K., Kimerling, R., Cronkite, R. C., McCutcheon, S., Frayne, S. M. 2012; 22 (2): E209-E215
View details for DOI 10.1016/j.whi.2011.09.001

View details for Web of Science ID 000209038900014
Who are the women and men in Veterans Health Administration's current spinal cord injury population? Journal of rehabilitation research and development Curtin, C. M., Suarez, P. A., Di Ponio, L. A., Frayne, S. M. 2012; 49 (3): 351-360
Abstract

Spinal cord injury (SCI) care is a high priority for the Veterans Health Administration (VHA). Aging Veterans, new cases of SCI from recent conflicts, and increasing numbers of women Veterans have likely changed the profile of the VHA SCI population. This study characterizes the current Veteran population with SCI with emphasis on healthcare utilization and women Veterans. We analyzed VHA administrative data from 2002-2003 and 2007-2008, analyzing composition, demographics, and healthcare use. The population is mostly male (>97%) and largely between 45 and 64 years old. Over 30% are over the age of 65. They are frequent users of healthcare, with an average of 21 visits per year. Women Veterans with SCI form a small but distinct subpopulation, being younger and less likely to be married and having a higher burden of disease. We must understand how the VHA population with SCI is changing to anticipate and provide the best care for these complex patients.

View details for PubMedID 22773195
Mental Illness and Warfarin Use in Atrial Fibrillation AMERICAN JOURNAL OF MANAGED CARE Walker, G. A., Heidenreich, P. A., Phibbs, C. S., Go, A. S., Chiu, V. Y., Schmitt, S. K., Ananth, L., Frayne, S. M. 2011; 17 (9): 617-624
Abstract

To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to maintain an International Normalized Ratio (INR) within the therapeutic range.Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.

View details for Web of Science ID 000295129700008

View details for PubMedID 21902447
Sexual Assault and Substance Use in Male Veterans Receiving a Brief Alcohol Intervention JOURNAL OF STUDIES ON ALCOHOL AND DRUGS Cucciare, M. A., Ghaus, S., Weingardt, K. R., Frayne, S. M. 2011; 72 (5): 693-700
Abstract

Many studies have documented the link between substance use and a history of sexual assault in women; however, few studies have examined this relationship in men. The purpose of this study was to explore the rates of sexual assault in a sample of male veterans reporting alcohol misuse and to further explore potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. We also explored the types of illicit drugs being used in the past 90 days and whether a clinical sample of male veterans reporting sexual assault are at greater odds of using these substances when compared with their peers with no history of sexual assault.Data were collected on a nationwide sample (N = 880) of male veterans receiving care in Veterans Administration outpatient mental health clinics.We found that 9.5% of our sample reported a history of sexual assault, and those with this history reported increased alcohol consumption, a greater number of alcohol-related consequences, and an increased likelihood of using an illicit substance in the past 90 days. The most commonly used illicit substances were cannabis, cocaine, and opiates. Those with sexual assault histories were also more likely to report risk factors that may exacerbate the negative effects of any level of alcohol consumption.Our findings highlight the burden of alcohol and illicit drug use among male veterans and suggest that substance use disorder treatment settings may be a context in which prevalence of a history of sexual assault is high. Our findings further support prior call for universal screening for sexual assault among this population.

View details for Web of Science ID 000295562500001

View details for PubMedID 21906496
Using Research to Transform Care for Women Veterans: Advancing the Research Agenda and Enhancing Research-Clinical Partnerships WOMENS HEALTH ISSUES Yano, E. M., Bastian, L. A., Bean-Mayberry, B., Eisen, S., Frayne, S., Hayes, P., Klap, R., Lipson, L., Mattocks, K., McGlynn, G., Sadler, A., Schnurr, P., Washington, D. L. 2011; 21 (4): S73-S83
Abstract

The purpose of this paper is to report on the outcomes of the 2010 VA Women's Health Services Research Conference, which brought together investigators interested in pursuing research on women veterans and women in the military with leaders in women's health care delivery and policy within and outside the VA, to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Building on priorities assembled in the previous VA research agenda (2004) and the research conducted in the intervening six years, we used an array of approaches to foster research-clinical partnerships that integrated the state-of-the-science with the informational and strategic needs of senior policy and practice leaders. With demonstrated leadership commitment and support, broad field-based participation, strong interagency collaboration and a push to accelerate the move from observational to interventional and implementation research, the Conference provided a vital venue for establishing the foundation for a new research agenda. In this paper, we provide the historical evolution of the emergence of women veterans' health services research and an overview of the research in the intervening years since the first VA women's health research agenda. We then present the resulting VA Women's Health Research Agenda priorities and supporting activities designed to transform care for women veterans in six broad areas of study, including access to care and rural health; primary care and prevention; mental health; post deployment health; complex chronic conditions, aging and long-term care; and reproductive health.

View details for DOI 10.1016/j.whi.2011.04.002

View details for Web of Science ID 000292785100005

View details for PubMedID 21724148
New Women Veterans in the VHA: A Longitudinal Profile WOMENS HEALTH ISSUES Friedman, S. A., Phibbs, C. S., Schmitt, S. K., Hayes, P. M., Herrera, L., Frayne, S. M. 2011; 21 (4): S103-S111
Abstract

The number of women veterans using Veterans Health Administration (VHA) services has increased rapidly, but the characteristics of women joining VHA are not well understood. We sought to describe sociodemographic characteristics, utilization, and retention of new and returning women VHA patients over a 7-year period.We identified women veterans who used VHA outpatient services from VHA Enrollment and Utilization files for fiscal years 2003 through 2009. "New" patients in a given year had no outpatient use within the prior 3 years. Patients were "retained" if they continued to use VHA in subsequent years.Of the 287,447 women veteran VHA outpatients in 2009, 40,000 (14%) were new to VHA in that year and over half had joined VHA since 2003. Nearly two thirds of these new patients were younger than 45, and 43% carried a service-connected disability status. Most new patients (88%) received primary care services in 2008, and 40% used mental health services. Repeated use of mental health services (at least three visits per year) nearly doubled among new patients (from 11% in 2003 to 20% in 2008). Among those using VHA primary care in 2006, 68% of new patients versus 91% of returning patients were retained in either of the subsequent 2 years.The influx of new women veterans seeking VHA services in recent years, combined with their high rate of retention within VHA, contribute to the marked increase in numbers of women veterans using VHA. Many require fairly intensive VHA services.

View details for DOI 10.1016/j.whi.2011.04.025

View details for Web of Science ID 000292785100008

View details for PubMedID 21724129
Health and Health Care of Women Veterans and Women in the Military: Research Informing Evidence-Based Practice and Policy WOMENS HEALTH ISSUES Yano, E. M., Frayne, S. M. 2011; 21 (4): S64-S66
View details for DOI 10.1016/j.whi.2011.04.030

View details for Web of Science ID 000292785100002

View details for PubMedID 21724145
Medical Care Needs of Returning Veterans with PTSD: Their Other Burden JOURNAL OF GENERAL INTERNAL MEDICINE Frayne, S. M., Chiu, V. Y., Iqbal, S., Berg, E. A., Laungani, K. J., Cronkite, R. C., Pavao, J., Kimerling, R. 2011; 26 (1): 33-39
Abstract

There has been considerable focus on the burden of mental illness (including post-traumatic stress disorder, PTSD) in returning Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, but little attention to the burden of medical illness in those with PTSD.(1) Determine whether the burden of medical illness is higher in women and men OEF/OIF veterans with PTSD than in those with No Mental Health Conditions (MHC). (2) Identify conditions common in those with PTSD.Cross-sectional study using existing databases (Fiscal Year 2006-2007).Veterans Health Administration (VHA) patients nationally.All 90,558 OEF/OIF veterans using VHA outpatient care nationally, categorized into strata: PTSD, Stress-Related Disorders, Other MHCs, and No MHC.(1) Count of medical conditions; (2) specific medical conditions (from ICD9 codes, using Agency for Health Research and Quality's Clinical Classifications software framework).The median number of medical conditions for women was 7.0 versus 4.5 for those with PTSD versus No MHC (p<0.001), and for men was 5.0 versus 4.0 (p<0.001). For PTSD patients, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders, and among men were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high frequency conditions were more common in those with PTSD than in those with No MHC.Burden of medical illness is greater in women and men OEF/OIF veteran VHA users with PTSD than in those with No MHC. Health delivery systems serving them should align clinical program development with their medical care needs.

View details for DOI 10.1007/s11606-010-1497-4

View details for Web of Science ID 000286338900014

View details for PubMedID 20853066
Depression treatment patterns among women veterans with cardiovascular conditions or diabetes WORLD PSYCHIATRY Sambamoorthi, U., Shen, C., Findley, P., Frayne, S., Banerjea, R. 2010; 9 (3): 177-182
Abstract

The study aimed to examine treatment patterns for depression among women veterans diagnosed with cardiovascular conditions or diabetes. We used longitudinal data from the 2002-2003 merged Veteran Health Administration (VHA) and Medicare files. Chi-square tests and multinomial logistic regression were performed to analyse depression treatment among veteran women with incident depressive episode and one of the following chronic conditions: diabetes or coronary artery disease or hypertension. Overall, 77% received treatment for depression, 54% with only antidepressants, 4% with only psychotherapy, and 19% with both. Multinomial logistic regression revealed that African American women were more likely to be in the no treatment group and were more likely than white women to receive psychotherapy rather than antidepressants. Older women and women with coronary artery disease only were less likely to receive treatment.

View details for Web of Science ID 000282859200012

View details for PubMedID 20975865
Military-Related Sexual Trauma Among Veterans Health Administration Patients Returning From Afghanistan and Iraq AMERICAN JOURNAL OF PUBLIC HEALTH Kimerling, R., Street, A. E., Pavao, J., Smith, M. W., Cronkite, R. C., Holmes, T. H., Frayne, S. M. 2010; 100 (8): 1409-1412
Abstract

We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.

View details for DOI 10.2105/AJPH.2009.171793

View details for Web of Science ID 000282354800015

View details for PubMedID 20558808
Sexual Violence, Posttraumatic Stress Disorder, and the Pelvic Examination: How Do Beliefs About the Safety, Necessity, and Utility of the Examination Influence Patient Experiences? JOURNAL OF WOMENS HEALTH Weitlauf, J. C., Frayne, S. M., Finney, J. W., Moos, R. H., Jones, S., Hu, K., Spiegel, D. 2010; 19 (7): 1271-1280
Abstract

Sexual violence and posttraumatic stress disorder (PTSD) have been linked to increased reports of distress and pain during the pelvic examination. Efforts to more fully characterize these reactions and identify core factors (i.e., beliefs about the examination) that may influence these reactions are warranted.This descriptive, cross-sectional study examines the relationship between sexual violence, PTSD, and women's negative reactions to the pelvic examination. Additional analyses highlight how maladaptive beliefs about the safety, necessity, and utility of the pelvic examination may contribute to these reactions. Materials andA total of 165 eligible women veterans were identified via medical record review and mailed a survey that assessed: (1) background information; (2) history of sexual violence; (3) current symptoms of posttraumatic stress disorder; (4) fear, embarrassment, distress, and pain during the pelvic examination; and (5) core beliefs about the examination. Ninety women (55% response rate) completed the survey.Women with both sexual violence and PTSD reported the highest levels of examination related fear: chi(2) = 18.8, p < .001; embarrassment: chi(2) = 21.2, p < .001; and distress: chi(2) = 18.2, p < .001. Beliefs that the examination was unnecessary or unsafe or not useful were more commonly reported in this group and were associated with higher levels of examination-related fear and embarrassment.Women with sexual violence and PTSD find the pelvic examination distressing, embarrassing, and frightening. Efforts to develop interventions to help reduce distress during the examination are warranted.

View details for DOI 10.1089/jwh.2009.1673

View details for Web of Science ID 000279428800007

View details for PubMedID 20509787
MENTAL ILLNESS AND GLYCEMIC CONTROL: DRILLING DEEPER 33rd Annual Meeting of the Society-of-General-Internal-Medicine/Session on Innovations in Medical Education Frayne, S., Moos, R., Berg, E., Laungani, K., Goldstein, M., Berlowitz, D., Miller, D., Holmes, T., Pogach, L. SPRINGER. 2010: 333–333
View details for Web of Science ID 000277282300276
Using Administrative Data to Identify Mental Illness: What Approach Is Best? AMERICAN JOURNAL OF MEDICAL QUALITY Frayne, S. M., Miller, D. R., Sharkansky, E. J., Jackson, V. W., Wang, F., Halanych, J. H., Berlowitz, D. R., Kader, B., Rosen, C. S., Keane, T. M. 2010; 25 (1): 42-50
Abstract

The authors estimated the validity of algorithms for identification of mental health conditions (MHCs) in administrative data for the 133 068 diabetic patients who used Veterans Health Administration (VHA) nationally in 1998 and responded to the 1999 Large Health Survey of Veteran Enrollees. They compared various algorithms for identification of MHCs from International Classification of Diseases, 9th Revision (ICD-9) codes with self-reported depression, posttraumatic stress disorder, or schizophrenia from the survey. Positive predictive value (PPV) and negative predictive value (NPV) for identification of MHC varied by algorithm (0.65-0.86, 0.68-0.77, respectively). PPV was optimized by requiring > or =2 instances of MHC ICD-9 codes or by only accepting codes from mental health visits. NPV was optimized by supplementing VHA data with Medicare data. Findings inform efforts to identify MHC in quality improvement programs that assess health care disparities. When using administrative data in mental health studies, researchers should consider the nature of their research question in choosing algorithms for MHC identification.

View details for DOI 10.1177/1062860609346347

View details for Web of Science ID 000273214000005

View details for PubMedID 19855046
Mental illness-related disparities in length of stay. Algorithm choice influences results JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT Frayne, S. M., Berg, E., Holmes, T. H., Laungani, K., Berlowitz, D. R., Miller, D. R., Pogach, L., Jackson, V. W., Moos, R. 2010; 47 (8): 709-718
Abstract

Methodological challenges arise when one uses various Veterans Health Administration (VHA) data sources, each created for distinct purposes, to characterize length of stay (LOS). To illustrate this issue, we examined how algorithm choice affects conclusions about mental health condition (MHC)-related differences in LOS for VHA patients with diabetes nationally (n = 784,321). We assembled a record-level database of all fiscal year (FY) 2003 inpatient care. In 10 steps, we sequentially added instances of inpatient care from various VHA sources. We processed databases in three stages, truncating stays at the beginning and end of FY03 and consolidating overlapping stays. For patients with MHCs versus those without MHCs, mean LOS was 17.7 versus 13.6 days, respectively (p < 0.001), for the crudest algorithm and 37.2 versus 21.7 days, respectively (p < 0.001), for the most refined algorithm. Researchers can improve the quality of data applied to VHA systems redesign by applying methodological considerations raised by this study to inform LOS algorithm choice.

View details for DOI 10.1682/JRRD.2009.08.0112

View details for Web of Science ID 000285074300006

View details for PubMedID 21110246
Does Opioid Therapy Affect Quality of Care for Diabetes Mellitus? AMERICAN JOURNAL OF MANAGED CARE Rose, A. J., Hermos, J. A., Frayne, S. M., Pogach, L. M., Berlowitz, D. R., Miller, D. R. 2009; 15 (4): 217-224
Abstract

To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids.Retrospective cohort study.We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004. Cases received at least 6 prescriptions for chronic opioids during 2004, while controls were randomly selected from among patients with diabetes who received no opioids. We compared process measures (glycosylated hemoglobin and low-density lipoprotein cholesterol levels tested and an eye examination performed) and outcome measures (glycosylated hemoglobin level < or =9.0% and low-density lipoprotein cholesterol level < or =130 mg/dL) between groups.Cases (n = 47,756) had slightly worse diabetes performance measures than controls (n = 220,912) after adjustment for covariates. For example, 86.4% of cases and 89.0% of controls had a glycosylated hemoglobin test during fiscal year 2004 (adjusted odds ratio, 0.69; P <.001). Among cases, receipt of higher-dose opioids was associated with additional decrement in diabetes performance measures, with a dose-response relationship.Chronic opioid therapy among patients within the Veterans Affairs system is associated with slightly worse diabetes performance measures compared with patients who do not receive opioids. However, patients receiving higher dosages of opioids had additional decrements in diabetes performance measures; these patients may be appropriate targets for interventions to improve their care for pain and diabetes.

View details for Web of Science ID 000265237100002

View details for PubMedID 19355794
Measuring quality of oral anticoagulation care: extending quality measurement to a new field. Joint Commission journal on quality and patient safety / Joint Commission Resources Rose, A. J., Berlowitz, D. R., Frayne, S. M., Hylek, E. M. 2009; 35 (3): 146-155
Abstract

Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care. LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION: Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care.Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.

View details for PubMedID 19326806
Distress and Pain During Pelvic Examinations Effect of Sexual Violence 112th Annual Meeting of the Association-of-Military-Surgeons-of-the-United-States Weitlauf, J. C., Finney, J. W., Ruzek, J. I., Lee, T. T., Thrailkill, A., Jones, S., Frayne, S. M. LIPPINCOTT WILLIAMS & WILKINS. 2008: 1343–50
Abstract

To estimate the range and severity of distress and pain during pelvic examinations among female veterans with and without histories of sexual violence, and to examine whether posttraumatic stress disorder explains additional variance in examination-related distress and pain above that accounted for by exposure to sexual violence.We employed a cross-sectional cohort design in which 67 selected female veterans completed self-administered questionnaires to assess history of sexual violence and experiences of distress and pain associated with the pelvic examination. A subsample of 49 completed an assessment for posttraumatic stress disorder approximately 2 weeks later.Distress associated with the pelvic examination was highest for women with prior sexual violence and posttraumatic stress disorder (median 5.49), next highest for women with sexual violence only (median 2.44), and lowest for women with neither (median 0), P=.015. Higher ratings of pain were also found among women with sexual violence (median 2.5) compared with those without (median 0), P=.04. However, posttraumatic stress disorder was not linked with increased pain from speculum insertion beyond that accounted for by sexual violence; limited power may have precluded detection of this effect.Distress and pain during pelvic examinations may indicate a history of previous sexual violence, particularly in those with posttraumatic stress disorder. Extra sensitivity to the special needs of this population is warranted and may contribute positively to the quality of patients' experiences.II.

View details for Web of Science ID 000261316200022

View details for PubMedID 19037045
Violence perpetration and childhood abuse among men and women in substance abuse treatment JOURNAL OF SUBSTANCE ABUSE TREATMENT Burnette, M. L., Ilgen, M., Frayne, S. M., Lucas, E., Mayo, J., Weitlauf, J. C. 2008; 35 (2): 217-222
Abstract

Despite an association between violence perpetration and substance use, the characteristics associated with violence among patients in treatment for substance use disorders (SUDs) are not well documented. Data were gathered from a national sample of men (n = 4,459) and women (n = 1,774) entering SUD treatment on history of violence perpetration, exposure to childhood physical abuse (CPA) and childhood sexual abuse (CSA), and reasons for entering treatment. Rates of violence perpetration were high (72% of men, 50% of women), and violence was associated with being referred by family members, prior SUD treatment, CPA, and CSA. In multivariate analyses, CPA was a significant correlate of violence perpetration across gender; however, CSA was only significant among women. Findings highlight the need for increased screening and treatment of violence perpetration among patients with SUD and suggest that CSA may be an important correlate of violence perpetration among women.

View details for DOI 10.1016/j.jsat.2007.10.002

View details for Web of Science ID 000258799100013

View details for PubMedID 18248945
Gender disparities in veterans health administration care - Importance of accounting for veteran status MEDICAL CARE Frayne, S. M., Yano, E. M., Nguyen, V. Q., Yu, W., Ananth, L., Chiu, V. Y., Phibbs, C. S. 2008; 46 (5): 549-553
Abstract

In an effort to assess and reduce gender-related quality gaps, the Veterans Health Administration (VHA) has promoted gender-based research. Historically, such appraisals have often relied on secondary databases, with little attention to methodological implications of the fact that VHA provides care to some nonveteran patients.To determine whether conclusions about gender differences in utilization and cost of VHA care change after accounting for veteran status.Cross-sectional.All users of VHA in 2002 (N = 4,429,414).Veteran status, outpatient/inpatient utilization and cost, from centralized 2002 administrative files.Nonveterans accounted for 50.7% of women (the majority employees) but only 3.0% of men. Among all users, outpatient and inpatient utilization and cost were far lower in women than in men, but in the veteran subgroup these differences decreased substantially or, in the case of use and cost of outpatient care, reversed. Utilization and cost were very low among women employees; women spouses of fully disabled veterans had utilization and costs similar to those of women veterans.By gender, nonveterans represent a higher proportion of women than of men in VHA, and some large nonveteran groups have low utilization and costs; therefore, conclusions about gender disparities change substantially when veteran status is taken into account. Researchers seeking to characterize gender disparities in VHA care should address this methodological issue, to minimize risk of underestimating health care needs of women veterans and other women eligible for primary care services.

View details for Web of Science ID 000255452100014

View details for PubMedID 18438204
Prevalence and health correlates of prostitution among patients entering treatment for substance use disorders ARCHIVES OF GENERAL PSYCHIATRY Burnette, M. L., Lucas, E., Ilgen, M., Frayne, S. M., Mayo, J., Weitlauf, J. C. 2008; 65 (3): 337-344
Abstract

Studies of prostitution have focused largely on individuals involved in the commercial sex trade, with an emphasis on understanding the public health effect of this behavior. However, a broader understanding of how prostitution affects mental and physical health is needed. In particular, the study of prostitution among individuals in substance use treatment would improve efforts to provide comprehensive treatment.To document the prevalence of prostitution among women and men entering substance use treatment, and to test the association between prostitution, physical and mental health, and health care utilization while adjusting for reported history of childhood sexual abuse, a known correlate of prostitution and poor health outcomes.Cross-sectional, secondary data analysis of 1606 women and 3001 men entering substance use treatment in the United States who completed a semistructured intake interview as part of a larger study.Self-reported physical health (respiratory, circulatory, neurological, and internal organ conditions, bloodborne infections) and mental health (depression, anxiety, psychotic symptoms, and suicidal behavior), and use of emergency department, clinic, hospital, or inpatient mental health services within the past year.Many participants reported prostitution in their lifetime (50.8% of women and 18.5% of men) and in the past year (41.4% of women and 11.2% of men). Prostitution was associated with increased risk for bloodborne viral infections, sexually transmitted diseases, and mental health symptoms. Prostitution was associated with use of emergency care in women and use of inpatient mental health services for men.Prostitution was common among a sample of individuals entering substance use treatment in the United States and was associated with higher risk of physical and mental health problems. Increased efforts toward understanding prostitution among patients in substance use treatment are warranted. Screening for prostitution in substance use treatment could allow for more comprehensive care to this population.

View details for Web of Science ID 000253672200011

View details for PubMedID 18316680
Healthcare preferences among lesbians: A focus group analysis JOURNAL OF WOMENS HEALTH Seaver, M. R., Freund, K. M., Wright, L. M., Tjia, J., Frayne, S. M. 2008; 17 (2): 215-225
Abstract

The healthcare needs of lesbians are not well understood. We sought to characterize lesbians' experiences with, and preferences for, women's healthcare.We conducted three age-stratified focus groups (18-29, 30-50, and >50 years) with a total of 22 participants using a semistructured interview guide to elicit lesbians' experiences and preferences. We analyzed transcripts of these audiotaped sessions using the constant comparative method of grounded theory. Community-dwelling women who self-identified as lesbian and responded to advertisements were selected on first-come basis.Participants voiced experiences and preferences for healthcare that emerged into three themes: desired models of care, desired processes of care, and desired patient-provider relationship. Each theme was further developed into multiple subthemes. Within the subthemes we identified issues that were specific to lesbians and those that were general women's health issues. Participants preferred, but did not always receive, care that is comprehensive in scope, person centered, nondiscriminatory, and inclusive of them as lesbians.Healthcare providers, institutions, and society should adopt an inviting, person-centered approach toward lesbians seeking healthcare, assure them access to healthcare information, and establish healthcare delivery systems that take all aspects of health into account.

View details for DOI 10.1089/jwh.2007.0083

View details for Web of Science ID 000254734700006

View details for PubMedID 18321173
The Veterans Health Administration and military sexual trauma AMERICAN JOURNAL OF PUBLIC HEALTH Kimerling, R., Gima, K., Smith, M. W., Street, A., Frayne, S. 2007; 97 (12): 2160-2166
Abstract

We examined the utility of the Veterans Health Administration (VHA) universal screening program for military sexual violence.We analyzed VHA administrative data for 185,880 women and 4139888 men who were veteran outpatients and were treated in VHA health care settings nationwide during 2003.Screening was completed for 70% of patients. Positive screens were associated with greater odds of virtually all categories of mental health comorbidities, including posttraumatic stress disorder (adjusted odds ratio [AOR]=8.83; 99% confidence interval [CI] = 8.34, 9.35 for women; AOR = 3.00; 99% CI = 2.89, 3.12 for men). Associations with medical comorbidities (e.g., chronic pulmonary disease, liver disease, and for women, weight conditions) were also observed. Significant gender differences emerged.The VHA policies regarding military sexual trauma represent a uniquely comprehensive health care response to sexual trauma. Results attest to the feasibility of universal screening, which yields clinically significant information with particular relevance to mental health and behavioral health treatment. Women's health literature regarding sexual trauma will be particularly important to inform health care services for both male and female veterans.

View details for DOI 10.2105/AJPH.2006.092999

View details for Web of Science ID 000251395900020

View details for PubMedID 17971558
Gender and use of care: Planning for tomorrow's veterans health administration JOURNAL OF WOMENS HEALTH Frayne, S. M., Yu, W., Yano, E. M., Ananth, L., Iqbal, S., Thrailkill, A., Phibbs, C. S. 2007; 16 (8): 1188-1199
Abstract

Historically, men have been the predominant users of Veterans Health Administration (VHA) care. With more women entering the system, a systematic assessment of their healthcare use and costs of care is needed. We examined how utilization and costs of VHA care differ in women veterans compared with men veterans.In this cross-sectional study using centralized VHA administrative databases, main analyses examined annual outpatient and inpatient utilization and costs of care (outpatient, inpatient, and pharmacy) for all female (n = 178,849) and male (n = 3,943,532) veterans using VHA in 2002, accounting for age and medical/mental health conditions.Women had 11.8% more outpatient encounters, 25.9% fewer inpatient days, and 11.4% lower total cost than men; after adjusting for age and medical comorbidity, differences were less pronounced (1.3%, 10.9%, and 2.8%, respectively). Among the 30.8% of women and 24.4% of men with both medical and mental health conditions, women used outpatient services more heavily than men (31.0 vs. 27.3 annual encounters).VHA's efforts to build capacity for women veterans must account for their relatively high utilization of outpatient services, which is especially prominent in women who have both medical and mental health conditions. Meeting their needs may require delivery systems integrating medical and mental healthcare.

View details for DOI 10.1089/jwh.2006.0205

View details for Web of Science ID 000250506100063

View details for PubMedID 17937572
Racial/ethnic differences in diabetes care for older veterans - Accounting for dual health system use changes conclusions 27th Annual Meeting of the Society-of-General-Internal-Medicine Halanych, J. H., Wang, F., Miller, D. R., Pogach, L. M., Lin, H., Berlowitz, D. R., Frayne, S. M. LIPPINCOTT WILLIAMS & WILKINS. 2006: 439–45
Abstract

Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients.We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes.Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files.In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results.Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.

View details for Web of Science ID 000237150000008

View details for PubMedID 16641662
Are there gender differences in diabetes care among elderly medicare enrolled veterans? JOURNAL OF GENERAL INTERNAL MEDICINE Tseng, C. L., Sambamoorthi, U., Rajan, M., Tiwari, A., Frayne, S., Findley, P., Pogach, L. 2006; 21: S47-S53
Abstract

To examine gender differences in diabetes care process measures and intermediate outcomes among veteran clinic users.A retrospective cohort study using Veterans Health Administration (VHA) and Medicare files of VHA clinic users with diabetes. Diabetes care process measures were tests for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C) values, and eye exams. Intermediate outcomes were HbA1c and LDL-C values below recommended thresholds. Chi-square tests and logistic regressions were used to assess gender differences.Study population included 3,225 women and 231,922 men veterans with diabetes, enrolled in Medicare fee-for-service and alive at the end of fiscal year 2000.Overall, there were no significant gender differences in HbA1c or LDL-C testing. However, women had higher rates in these process measures than men among the non-African American minorities. Women were more likely to have completed eye exams (odds ratio [OR]=1.11; 99% confidence interval [CI]=1.10, 1.23) but were less likely to have LDL-C under 130 mg/dL (OR=0.77; 99% CI=0.69, 0.87).Among VHA patients with diabetes, clinically significant gender inequality was not apparent in most of diabetes care measures. However, there was evidence of better care among nonwhite and non-African American women than their male counterparts. Further research on interaction of race and gender on diabetes care is needed. This includes evaluation of integrated VHA women's health programs as well as cultural issues. Lower LDL-C control among women suggests areas of unmet needs for women and opportunities for future targeted quality improvement interventions at system and provider levels.

View details for DOI 10.1111/j.1525-1497.2006.00374.x

View details for Web of Science ID 000235954500010

View details for PubMedID 16637945
Toward a VA women's health research agenda: Setting evidence-based priorities to improve the health and health care of women veterans JOURNAL OF GENERAL INTERNAL MEDICINE Yano, E. M., Bastian, L. A., Frayne, S. M., HOWELL, A. L., Lipson, L. R., McGlynn, G., Schnurr, P. P., Seaver, M. R., Spungen, A. M., Fihn, S. D. 2006; 21: S93-S101
Abstract

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research.

View details for DOI 10.1111/j.1525-1497.2006.00381.x

View details for Web of Science ID 000235954500017

View details for PubMedID 16637953
Health status among 28,000 women veterans - The VA women's health program evaluation project JOURNAL OF GENERAL INTERNAL MEDICINE Frayne, S. M., Parker, V. A., Christiansen, C. L., Loveland, S., Seaver, M. R., Kazis, L. E., Skinner, K. M. 2006; 21: S40-S46
Abstract

Male veterans receiving Veterans Health Administration (VA) care have worse health than men in the general population. Less is known about health status in women veteran VA patients, a rapidly growing population.To characterize health status of women (vs men) veteran VA patients across age cohorts, and assess gender differences in the effect of social support upon health status.Data came from the national 1999 Large Health Survey of Veteran Enrollees (response rate 63%) and included 28,048 women and 651,811 men who used VA in the prior 3 years.Dimensions of health status from validated Veterans Short Form-36 instrument; social support (married, living arrangement, have someone to take patient to the doctor).In each age stratum (18 to 44, 45 to 64, and > or =65 years), Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were clinically comparable by gender, except that for those aged > or =65, mean MCS was better for women than men (49.3 vs 45.9, P<.001). Patient gender had a clinically insignificant effect upon PCS and MCS after adjusting for age, race/ethnicity, and education. Women had lower levels of social support than men; in patients aged <65, being married or living with someone benefited MCS more in men than in women.Women veteran VA patients have as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services. Their ill health occurs in the context of poor social support, and varies by age.

View details for DOI 10.1111/j.1525-1497.2006.00373.x

View details for Web of Science ID 000235954500009

View details for PubMedID 16637944
Disparities in diabetes care - Impact of mental illness ARCHIVES OF INTERNAL MEDICINE Frayne, S. M., Halanych, J. H., Miller, D. R., Wang, F., Lin, H., Pogach, L., Sharkansky, E. J., Keane, T. M., Skinner, K. M., Rosen, C. S., Berlowitz, D. R. 2005; 165 (22): 2631-2638
Abstract

Emerging evidence indicates that patients with mental health conditions (MHCs) may receive less intensive medical care. Diabetes serves as a useful condition in which to test for MHC-related disparities in care. We examined whether quality measures for diabetes care are worse for patients with or without MHCs.This national, cross-sectional study included 313 586 noninstitutionalized Veterans Health Administration patients with diabetes (identified from diagnostic codes and prescriptions) whose Veterans Health Administration facility transmitted laboratory data to a central database; 76 799 (25%) had MHCs (based on diagnostic codes for depressed mood, anxiety, psychosis, manic symptoms, substance use disorders, personality disorders, and other categories). National data from Veterans Health Administration records, Medicare claims, and a national survey were linked to characterize 1999 diabetes care.Failure to meet diabetes performance measures was more common in patients with MHCs: unadjusted odds ratio (95% confidence interval) was 1.24 (1.22-1.27) for no hemoglobin A(1c) testing, 1.25 (1.23-1.28) for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07) for no eye examination, 1.32 (1.30-1.35) for poor glycemic control, and 1.17 (1.15-1.20) for poor lipemic control. Disparities persisted after case mix adjustment and were more pronounced with specific MHCs (psychotic, manic, substance use, and personality disorders). The percentage not meeting diabetes care standards increased with increasing number of MHCs.Patients with mental illness merit special attention in national diabetes quality improvement efforts.

View details for Web of Science ID 000233883800015

View details for PubMedID 16344421
Effect of patient gender on late-life depression management JOURNAL OF WOMENS HEALTH Frayne, S. M., Skinner, K. M., Lin, H., Ash, A. S., Freund, K. M. 2004; 13 (8): 919-925
Abstract

To determine whether patient gender influences physicians' management of late-life major depression in older and younger elderly patients.In 1996-2001, physician subjects viewed a professionally produced videotape vignette portraying an elderly patient meeting diagnostic criteria for major depression, then answered interviewer-administered questions about differential diagnosis and treatment. Patient gender and other characteristics were systematically varied in different versions of the videotape, but clinical content was held constant. This was a stratified random sample of 243 internists and family physicians with Veterans Health Administration (VA) or non-VA ambulatory care practices in the Northeastern United States. Outcomes were whether physicians followed a guideline-recommended management approach: treating with antidepressants or mental health referral or both and seeing the patient for follow-up within 2 weeks.Only 19% of physicians recommended treating depression (12% recommended antidepressants and 7% mental health referral), and 43% recommended follow-up within 2 weeks. Patient gender did not influence management recommendations in either younger old (67 year old) or older old (79 year old) patients (p > 0.12 for all comparisons).Gender disparities previously documented in the management of major conditions are not seen for the management of depression, a potentially stigmatized condition that does not require resource-intense interventions.

View details for Web of Science ID 000225396100007

View details for PubMedID 15671707
Conceptual bases of Christian, faith-based substance abuse rehabilitation programs: qualitative analysis of staff interviews. Substance abuse McCoy, L. K., Hermos, J. A., Bokhour, B. G., Frayne, S. M. 2004; 25 (3): 1-11
Abstract

Faith-based substance abuse rehabilitation programs provide residential treatment for many substance abusers. To determine key governing concepts of such programs, we conducted semi-structured interviews with sample of eleven clinical and administrative staff referred to us by program directors at six, Evangelical Christian, faith-based, residential rehabilitation programs representing two large, nationwide networks. Qualitative analysis using grounded theory methods examined how spirituality is incorporated into treatment and elicited key theories of addiction and recovery. Although containing comprehensive secular components, the core activities are strongly rooted in a Christian belief system that informs their understanding of addiction and recovery and drives the treatment format. These governing conceptions, that addiction stems from attempts to fill a spiritual void through substance use and recovery through salvation and a long-term relationship with God, provide an explicit, theory-driven model upon which they base their core treatment activities. Knowledge of these core concepts and practices should be helpful to clinicians in considering referrals to faith-based recovery programs.

View details for PubMedID 16150675
Burden of medical illness in women with depression and posttraumatic stress disorder National Meeting of the Society-of-General-Internal-Medicine Frayne, S. M., Seaver, M. R., Loveland, S., Christiansen, C. L., Spiro, A., Parker, V. A., Skinner, K. M. AMER MEDICAL ASSOC. 2004: 1306–12
Abstract

Depression and posttraumatic stress disorder (PTSD) are important women's health issues. Depression is known to be associated with poor physical health; however, associations between physical health and PTSD, a common comorbidity of depression, have received less attention.To examine number of medical symptoms and physical health status in women with PTSD across age strata and benchmark them against those of women with depression alone or with neither depression nor PTSD.A random sample of Veterans Health Administration enrollees received a mailed survey in 1999-2000 (response rate, 63%). The 30 865 women respondents were categorized according to whether a health care provider had ever told them that they had PTSD, depression (without PTSD), or neither. Outcomes were self-reported medical conditions and physical health status measured with the Veterans SF-36 instrument, a version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) modified for use in veteran populations.Across age strata, women with PTSD (n = 4348) had more medical conditions and worse physical health status (physical functioning, role limitations due to physical problems, bodily pain, and energy/vitality scales from the Veterans SF-36) than women with depression alone (n = 7580) or neither (n = 18 937). In age-adjusted analyses, the Physical Component Summary score was on average 3.4 points lower in women with depression alone and 6.3 points lower in women with PTSD than in women with neither (P<.001).Posttraumatic stress disorder is associated with a greater burden of medical illness than is seen with depression alone. The presence of PTSD may account for an important component of the excess medical morbidity and functional status limitations seen in women with depression.

View details for Web of Science ID 000222325400007

View details for PubMedID 15226164
Depression management in medical clinics: Does healthcare sector make a difference? 24th Annual Meeting of the Society-of-General-Internal-Medicine Frayne, S. M., Freund, K. M., Skinner, K. M., Ash, A. S., Moskowitz, M. A. SAGE PUBLICATIONS INC. 2004: 28–36
Abstract

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P < .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

View details for Web of Science ID 000188437300005

View details for PubMedID 14977023
Health status among women with menstrual symptoms JOURNAL OF WOMENS HEALTH Barnard, K., Frayne, S. M., Skinner, K. M., Sullivan, L. M. 2003; 12 (9): 911-919
Abstract

Chronic diseases have been associated with decrements in health status, as measured by the Medical Outcomes Study's Short Form-36 (SF-36). Menstrual symptoms (including irregular menses, menorrhagia, dysmenorrhea and premenstrual symptoms) are common, but little is known about their impact on health status. We sought to determine the prevalence of menstrual symptoms and the degree to which these symptoms affect health status.This was a mailed survey including questions about sociodemographic characteristics, military experiences, current physical symptoms and medical conditions, mental health, health status (SF-36), and life experiences. The participants were a nationally representative, randomly selected sample of women veterans who had made at least one ambulatory visit to a Veterans Affairs facility between July 1, 1994 and June 30, 1995. The main outcome measures were eight domains of the SF-36 health status questionnaire.Among 3632 respondents (58.4% response rate), 1744 were menstruating women and formed the analytical sample for this study. Among these women (mean age 35.8), 67% reported one or more menstrual symptoms. Women with menstrual symptoms had significantly lower scores for all domains of the SF-36 (p < 0.01), except energy and vitality (p < 0.05), both before and after adjusting for sociodemographic, psychosocial, and comorbidity variables.Women veterans who report one or more menstrual symptoms have significantly lower health status compared with those reporting none. Clinicians providing care for women should be attuned to the potential impact of menstrual symptoms on the lives of their patients.

View details for Web of Science ID 000188532700011

View details for PubMedID 14670171
Sexual assault while in the military: violence as a predictor of cardiac risk? Violence and victims Frayne, S. M., Skinner, K. M., Sullivan, L. M., Freund, K. M. 2003; 18 (2): 219-225
Abstract

The purpose of this article is to determine whether known cardiac risk factors are more prevalent among women veterans who report having sustained sexual assault while in the military. We surveyed a random sample of 3,632 women veterans using Veterans Administration (VA) ambulatory care nationally. Obesity, smoking, problem alcohol use, sedentary lifestyle, and hysterectomy before age 40 were found to be more common in women reporting a history of sexual assault while in the military than in women without such history. An association between myocardial infarction and prior sexual assault history may be mediated in part by known cardiac risk factors.

View details for PubMedID 12816405
Help-seeking behaviors of blacks and whites dying from coronary heart disease ETHNICITY & HEALTH Frayne, S. M., Crawford, S. L., McGraw, S. A., Smith, K. W., McKinlay, J. B. 2002; 7 (2): 77-86
Abstract

This study sought to determine whether blacks and whites with life-threatening cardiac events differ in likelihood of help seeking, types of help sought, or likelihood of reaching the hospital before death.Death certificates were used to identify all coronary heart disease-related deaths occurring in 1988-89 among 45- to 74-year-old, black and white, non-institutionalized residents of three contiguous inner-city districts in Boston, Massachusetts, USA. An informant was interviewed about the decedent's health status, access to care and pre-mortal help-seeking behaviors.Among the 232 decedents analyzed, there were no racial differences in the likelihood of help seeking. Among those who sought help, there were no racial differences in the likelihood of reaching the hospital. However, blacks were more likely than whites to engage in two specific help-seeking behaviors: calling the 911 emergency system, and trying to reach an emergency room.In an area where blacks and whites were similar with respect to socioeconomic status and access to care, race did not affect the likelihood of help seeking or the likelihood of succeeding in reaching the hospital before death.

View details for DOI 10.1080/1355785022000038560

View details for Web of Science ID 000179550200001

View details for PubMedID 12511195
Attitudes of primary care physicians toward cancer-prevention trials: A focus group analysis JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION Frayne, S. M., Mancuso, M., Prout, M. N., Freund, K. M. 2001; 93 (11): 450-457
Abstract

Recruitment of low-income and minority women to cancer-prevention trials requires a joint effort from specialists and primary care providers. We sought to assess primary care providers' attitudes toward participating in cancer-prevention trial recruitment.We conducted a focus group with seven Boston-based primary care providers serving low-income and minority women. Providers discussed knowledge, attitudes, and beliefs regarding their role in recruitment to prevention trials.A qualitative analysis of the focus group transcript revealed nine categories. Three categories related specifically to the primary care physician: 1) the dual role physicians play as advocates for both patient and research; 2) threats to maintaining the primary care relationship; and 3) general philosophy toward prevention. An additional six categories could be subdivided as they apply to the primary care physician, the patient, and the community: 4) trust/commitment; 5) benefits of the research; 6) access to the research; 7) knowledge and recall of the research; 8) influences of media coverage about the research; and 9) cultural sensitivity.Investigators conducting cancer-prevention trials must address the concerns of primary care physicians to optimize recruitment of subjects- especially low-income and minority women-into trials.

View details for Web of Science ID 000172158500008

View details for PubMedID 11730121
The prevalence of military sexual assault among female veterans' administration outpatients JOURNAL OF INTERPERSONAL VIOLENCE Skinner, K. M., Kressin, N., Frayne, S., Tripp, T. J., Hankin, C. S., Miller, D. R., Sullivan, L. M. 2000; 15 (3): 291-310
View details for Web of Science ID 000085225700005
Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military JOURNAL OF TRAUMATIC STRESS Hankin, C. S., Skinner, K. M., Sullivan, L. M., Miller, D. R., Frayne, S., Tripp, T. J. 1999; 12 (4): 601-612
Abstract

Among a national sample of 3,632 women VA outpatients, we determined self-reported prevalence of sexual assault experienced during military service and compared screening prevalence for current symptoms of depression and alcohol abuse between those who did and did not report this history. Data were obtained by mailed questionnaire. Military-related sexual assault was reported by 23%. Screening prevalence for symptoms of current depression was 3 times higher and for current alcohol abuse was 2 times higher among those who reported experiencing military-related sexual assault. Recent mental health treatment was reported by 50% of those who reported experiencing sexual assault during military service and screened positive for symptoms of depression, and by 40% of those who screened positive for symptoms of alcohol abuse.

View details for Web of Science ID 000084818700005

View details for PubMedID 10646179
Medical profile of women veterans administration outpatients who report a history of sexual assault occurring while in the military JOURNAL OF WOMENS HEALTH & GENDER-BASED MEDICINE Frayne, S. M., Skinner, K. M., Sullivan, L. M., Tripp, T. J., Hankin, C. S., Kressin, N. R., Miller, D. R. 1999; 8 (6): 835-845
Abstract

To profile differences in current physical symptoms and medical conditions among women users of Veterans Administration (VA) health services with and without a self-reported history of sexual assault sustained during military service, we conducted a cross-sectional analysis of a nationally representative, random sample of women veterans using VA outpatient services (n = 3632). A self-administered, mailed survey asked whether women had sustained sexual assault while in the military and requested information about a spectrum of physical symptoms and medical conditions. A history of sexual assault while in the military was reported by 23% of women VA users and was associated with current physical symptoms and medical conditions in every domain assessed. For example, women who reported sexual assault were more likely to indicate that they had a "heart attack" within the past year, even after adjusting for age, hypertension, diabetes, and smoking history (OR 2.3, 95% CI 1.3-4.0). Among women reporting a history of sexual assault while in the military, 26% endorsed > or = 12 of 24 symptoms/conditions, compared with 11% of women with no reported sexual assault while in the military (p < 0.001). Clinicians need to be attuned to the high frequency of sexual assault occurring while in the military reported by women VA users and its associated array of current physical symptoms and medical conditions. Clinicians should consider screening both younger and older patients for a sexual violence history, especially patients with multiple physical symptoms.

View details for Web of Science ID 000082361600016

View details for PubMedID 10495264
Patient satisfaction with Department of Veterans Affairs health care: Do women differ from men? MILITARY MEDICINE Kressin, N. R., Skinner, K., Sullivan, L., Miller, D. R., Frayne, S., Kazis, L., Tripp, T. 1999; 164 (4): 283-288
Abstract

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

View details for Web of Science ID 000079664600011

View details for PubMedID 10226456
The exclusion of non-English-speaking persons from research JOURNAL OF GENERAL INTERNAL MEDICINE Frayne, S. M., Burns, R. B., Hardt, E. J., Rosen, A. K., Moskowitz, M. A. 1996; 11 (1): 39-43
Abstract

We sought to determine how often non-English-speaking (NES) persons are excluded from medical research. DESIGN. Self-administered survey.A Medline search identified all original investigations on provider-patient relations published in major U.S. journals from 1989 through 1991, whose methodologies involved direct interaction between researcher and subject (N = 216). Each study's corresponding author was surveyed; 81% responded.Of the 172 respondents, 22% included NES persons; among these includers, 16% had not considered the issue during the study design process, and 32% thought including the NES had affected their study results. Among the 40% who excluded the NES (excluders), the most common reason was not having thought of the issue (51%), followed by translation issues and recruitment of bilingual staff. The remaining 35% (others) indicated that there were no NES persons in their study areas.NES persons are commonly excluded from provider-patient communication studies appearing in influential journals, potentially limiting the generalizability of study findings. Because they are often excluded through overnight, heightened awareness among researchers and granting institutions, along with the development of valid instruments in varied languages, may increase representation of non-English-speaking subjects in research.

View details for Web of Science ID A1996TR84200006

View details for PubMedID 8691285
TO DISCHARGE OR NOT TO DISCHARGE - ETHICS OF CARE FOR AN UNDOCUMENTED IMMIGRANT JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Asch, S., Frayne, S., Waitzkin, H. 1995; 6 (1): 3-9
View details for Web of Science ID A1995RJ91900001

View details for PubMedID 7734634
PREVALENCE OF DOMESTIC VIOLENCE AMONG PATIENTS IN 3 AMBULATORY CARE INTERNAL-MEDICINE CLINICS JOURNAL OF GENERAL INTERNAL MEDICINE GIN, N. E., Rucker, L., Frayne, S., CYGAN, R., Hubbell, F. A. 1991; 6 (4): 317-322
Abstract

To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence.Survey using a self-administered, anonymous questionnaire.Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center.We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire.28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status.The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.

View details for Web of Science ID A1991FX36800008

View details for PubMedID 1890502

Professor of Medicine (General Medical Discipline) at the Palo Alto Veterans Affairs Health Care System

Medicine - Primary Care and Population Health

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